Monday, January 28, 2008

Health & the power of suggestion

We know that the placebo effect is of importance in helping to cure people of diseases and illnesses - eating that worthless little pill that you believe can resolve your problems might do so. For that matter being married or going to church promotes your health also.

A related issue is whether joining a 'support group' or 'thinking positive' help cure ailments.

A partial answer I have described in previous posts – at least in relation to cancer - is negative. If you are married and have lots of friends then you will be more resilient but providing ‘friends’ or 'thinking positive' once you are diagnosed with this illness probably won’t help.

Of course it might work with respect to other illnesses.

This Salon article by a medical historian, Anne Harrington, who looks at the reasons people hold the contrary view that 'support groups' and 'positive thinking' can help*. One background idea is that of the exorcism of evil spirits or its secular equivalent, hypnotism. This is the basis for believing in the power of suggestion and is, of course, the basis of placebo effects. In addition, the Bible itself teaches that you can be cured of a disease by faith alone. Furthermore there is the idea that certain emotions can make you sick - this can be traced to Freud.

There are also, of course, temptations to believe in mind-body connections for intractable illnesses and chronic conditions that conventional medicine cannot deal with. It might be a matter of 'what do you have to lose?'

This puts issues of 'positive thinking' and 'support groups' in a wholly negative light. If, however, the power of suggestion works with respect to placebos there is no reason to rule it out with respect to other approaches such as 'positive thinking' and having 'support groups'. In addition quality of life might be improved even with a persisting illness up to the time of death. This view is inconsistent with earlier arguments I have made against using optimism as a palliative and instead promoting the ideal of a rational death.

Incidentally Harrington’s observation that the language of ‘stress’ only developed after World War 2 is interesting. Before that time people simply went to bed exhausted when they were, what we would describe, as 'stressed out' – it was called neurasthenia. It might be that we deal with unhappy events in our life in ‘socially-approved’ ways. In the past these were physical ways but these days it is seen as psychological. This is a further basis on which we build the belief that illness can be dealt with by dispelling negative thoughts and being positive.

*This link is temperamental - the unedited article follows:

Minding our health.

If chemo fails, there's always positive thinking, or so we'd like to believe. Medical historian Anne Harrington looks at our persistent faith in curing ourselves by Katharine Mieszkowski

If you have ever observed a workaholic boss barking orders at an underling and thought, "That dunderhead is headed for a heart attack," you've dabbled in mind-body medicine. If you've ever told a sick friend to "think positive," implying that she'll feel better if she just stays focused on the bright side, you've ventured there, too.

Mind-body medicine is the belief that thoughts and feelings have the power to both sicken the body and heal it. In "The Cure Within: A History of Mind-Body Medicine," Harvard professor Anne Harrington traces the migration of this idea from the alternative-health margins into the mainstream. The chairwoman of the history of science department at Harvard University, Harrington is less concerned with debunking dubious theories about magically thinking yourself well than she is with understanding where these beliefs come from, how they shape our experience of illness and why they persist.

Her captivating survey ranges from 19th century hypnosis to 1950s self-help books about the power of positive thinking to contemporary efforts to understand what happens to the brain during meditation by hooking Buddhist monks up to MRI (magnetic resonance imaging) machines. New theories about the mind's impact on the body emerge and old ones are reconceived -- even stress turns out to be a recent invention -- as each era grapples to make sense of illness, and sick patients, let down by the medical establishment, seek out alternatives.
Salon spoke with Harrington by phone from her office at Harvard in Cambridge, Mass.

What is mind-body medicine?

It's a lot of different things, and that's what makes it both interesting and controversial and why people fight so much about it. Mind-body medicine is a patchwork of ideas about the way in which we think that our minds make us sick, and might make us well. The big ideas influence how we think about disease, how we seek out different care for ourselves, even how we experience our bodies in health and illness.

Let's take one of those ideas -- the power of suggestion. When was its heyday?

The power of suggestion emerged in its modern form in the late 19th century around efforts to make sense of hypnosis, in which certain kinds of people, in response to the instructions of a powerful authority figure, like a doctor, would experience changes in their bodies -- they might sweat, they might become paralyzed, they might do ridiculous things. The interpretation was that they were responding to the instructions of this authority figure, that this was an interpersonal drama.

But the interesting thing about the power of suggestion in hypnosis is that it's an emergent product of a much, much older interpersonal drama that actually goes back to medieval times, the drama of the exorcist who exorcises demons from the bodies of possessed people and exerts control over the demon. It was felt that demons had to do what the exorcist said, just as we believe we have to do what the hypnotist says.

So the hypnotist is a secular version of the exorcist?

Yes. Maybe that helps to explain why there is still this frisson of anxiety and mystery around this kind of interpersonal drama. There's a deep historical memory of the more mystical or supernatural authority that these kinds of people used to hold over patients.

How does the power of suggestion exhibit itself today?

In our fears around placebos and the effects of placebos.

The placebo effect was initially understood to be powered by the power of suggestion. They're inert pills or tonics or powders -- why do they work? Well, they don't really work, but patients think they work, and they think they work because their doctors tell them they're going to work, and it's really just suggestion.

Since the early 1980s, our thinking about the placebo effect has undergone a sea change. We now think if you take a placebo, and you believe it's going to work, your brain is going to change, and that might in turn lead to a cascade of effects that will cause your body to heal faster.

Our thinking about the placebo has shifted from the power of the authority figure to the power of our own positive thinking?

That's how I see the history. There was a self-help book about the placebo effect that said the placebo effect is the good news of our time. You can be cured by nothing but yourself. So now we attribute the effects of placebos to ourselves and how our own brains change. We see it as an empowering thing, as opposed to maybe 60 or 70 years ago, when we saw it as evidence of our susceptibility, our vulnerability to the influences of others.

Where did this notion of the power of positive thinking come from?

Well, the deep roots lie way back in biblical promises that if you have faith, you can be healed through faith.

People said: "Look, if the Bible tells us we can be healed through faith, then why not really take it at its word, and cultivate faith?" Chant mantras. Visualize. Do all the things that we now think of as New Age tricks. These go back to the middle-to-late 19th century.

How is the power of positive thinking still alive today?

It's still very much alive around our belief that we can use placebos to heal ourselves. Yet the power of positive thinking actually, just a couple of months ago, received a setback. In December there was an article published in the medical journal Cancer that claimed [the researchers] had attempted to see whether or not emotional well-being and a particularly positive attitude had any influence on the course of cancer. There was no effect.

I think people hold onto this belief in the power of positive thinking because there is a kind of moral -- not only a scientific, but a moral -- persuasiveness to this idea that if you believe, and refuse to admit defeat, you'll be rewarded for that. The power of positive thinking has really taken hold in areas where there are no quick fixes in modern medicine. So cancer has been a very important area.

You write about how it was once thought that being in a support group could extend the life of a terminal cancer patient. Even though that notion has since been debunked by numerous studies, it still exists. Why do you think it's such a persistent idea?

Love heals. This is yet another story about how friends are the best medicine. Community heals us not just of that which ails our souls, but maybe of that which ails our body. And, to be fair, there is a fair amount of epidemiological data that suggests [community isn't just about] wistfulness or nostalgia over some vision about what life used to be like before we all became disconnected and lonely.

Epidemiological data suggests that people who are more embedded, who are married, who go to church, who claim to have more friends tend, on average, to be more resistant to the slings and arrows. They live, on average, longer. What has experienced a blow is the idea that you could operationalize this idea by turning it into a therapy for people who are already very sick. In other words, you could take heart patients or take people in an advanced stage of cancer and put them in support groups and give them the community that they should have had all their lives.
That you could institutionalize community.

Yeah, you turn it into a kind of medicine, and a 90-minute dose a week might extend a person's life. Originally, there was a clinical trial by David Spiegel at Stanford that suggested it was possible to do this. An initial study seemed to indicate that women with metastasized advanced-stage cancer who participated in a support group for 90 minutes a week lived on average twice as long as those who didn't. But he hasn't been able to replicate, and others have not been able to replicate.

How did the idea come about that certain personality types get particular diseases?

We all know about these ideas. You tell me -- the guy who blows his top constantly, is constantly screaming at his employees, what's he going to die of?

A heart attack.

And the woman who constantly lets herself be a doormat, and lets her husband abuse her, and says, "Don't mind me, I'm just going to sit in the dark, and not bother anyone." What disease is she likely to get?


The idea that repressing certain emotions can make you sick in very specific ways comes from the Freudian legacy. Psychoanalysts thought there was a relationship between the kind of personality you have and the kind of neurosis you would develop -- certain personalities become obsessive or become anxious or become depressive. Some within the Freudian tradition extended this way of thinking to physical diseases. A woman named Flanders Dunbar became particularly influential in developing this idea that there were personality types more prone to developing certain kinds of physical disorders.

Everyone has heard of accident proneness. She coined this idea that there was a certain personality type that was more prone to falling down stairs or to crashing a car. This was taken very seriously in its time. Articles in the popular press said that we need to know about these things, because the number of accidents on the highways is rising sharply and we don't understand what kind of unconscious, repressed rage might be responsible for a great many of them.

How has this held up? I mean, obviously, these ideas have continued in the popular imagination, but what about in the medical world?

There are still some people who believe a type of personality -- depressive and emotionally repressed -- might be associated with a greater susceptibility to a poor outcome of cancer. But people are not so likely to talk about cancer-prone personalities [as] they were even a decade or two ago. And when they did talk about it then, they made a great point of insisting, "We're not blaming you. This is empowering, because if you know the kinds of personality or behavioral style that might cause you to have a bad outcome, you can change them."

There's that great Susan Sontag quote: "Patients who are instructed that they have, unwittingly, caused their disease are also being made to feel that they have deserved it."

That's right, and this is what is said over and over again by critics. You know about the idea of the Type A personality?


When I talk to my students here at Harvard, everyone has heard of Type A. The interesting thing is that none of my students know that it was supposed to make them vulnerable to heart attack. They're all Type A. They're Type A because they're workaholics, and they're really stressed and they drive themselves. For them, it's a badge of honor. But back in the late '50s, when this idea was originally developing, the argument was that this personality type was at greater risk of succumbing to heart disease. By the '80s, the data didn't really hold up. This personality type tended to include people who were kind of angry, hostile and cynical in addition to being workaholics. And it was claimed that it was cynicism and anger that actually induce the heart disease, not the workaholism.

I was fascinated to read that stress is really a modern invention. Where did it come from, and what did people think they were suffering from before?

People suffered from exhaustion, they didn't suffer from stress. And becoming exhausted, what was widely called neurasthenia, was not the same as suffering from a disease of stress. Instead of becoming all wound up and at risk of cracking, people would take to their beds. They wouldn't be able to bear any bright lights or surprises. They suffered from various kinds of stomach ailments and skin rashes, but it didn't look like our stress.

The language of stress and the whole understanding of how you're supposed to feel when you're stressed emerge only after the Second World War, out of new ideas coming out of the laboratory of what happens to animals' bodies when they're faced with a threat -- the "fight-or-flight response," which was a product of the '20s and '30s. It gets married in the context of the Second World War with concerns about the intense challenges that were being faced by the soldiers, particularly bomber pilots. Out of military anxieties and laboratory data and a general sense in the postwar era that the world was becoming very fast-paced and that American men, in particular, were suffering from the capitalist grind, stress was born.

It's not just that people didn't have the word "stress" for what they were experiencing -- they were actually experiencing something different from what we would call "stress" today?
It's possible. It's possible for our bodies to have a history, for the way that we experience the distresses of our life to change in accordance with what our culture tells us are the rules. I wasn't alive in the late 19th century. I can't emphatically say, "Absolutely, and here's why." But I think there is good reason to at least take that possibility seriously, that the inner experience of distress shifts according to the story that we live in.

Don't patients often turn to mind-body medicine when they feel let down by conventional medicine, as in the early days of the AIDS epidemic, or the holistic response to cancer in the '80s?

Exactly. Mind-body medicine is always living alongside and in the cracks of the dominant approach to disease and healing that we have in our culture. Mainstream medicine says leave your mind out of it, you've got a bodily disorder, and we're going to cure it with some kind of physical intervention. And mainstream medicine is often pretty good at this. So as long as it's doing its job very well, a lot of us are very happy to embrace it.

When do we find ourselves being tempted by or drawn to the other understandings of mind-body medicine? It's often when mainstream medicine lets us down or can't provide therapies.

Often around chronic disorders, it doesn't seem to do justice to all the complex ways in which our diseases are more than just diseases, [in that] they're part of who we are. And we need to make sense of them as part of who we are.

There is a sensibility of discontent that runs through mind-body medicine, a sensibility of being a rebellious alternative, and therefore it attracts patients who are discontented and inclined, perhaps, to feeling rebellious.

Where is mind-body medicine influential today?

There is a lot of interest right now in meditation and the ways in which advanced practice of meditation might be able to sculpt the brain. It links to new ideas about neuroplasticity, about how a meditation practice might be able to rewire the brain in ways that might make people happier and healthier.
Some of the best science may be happening in slightly quieter, less sensational ways than some of this meditation stuff. Neuroimmune interactions might prove to be very important for pushing thinking forward, but certainly where the attention is now is around monks using MRI machines and what they might teach the rest of us about our human potential.

Do you think there will always be a give-and-take between mainstream and mind-body medicine?

I think part of it will always remain by design and by desire outside of the mainstream because large parts of it want to be the face of medicine that defies what the mainstream says is possible. It wants to resist and rebel and offer alternatives. I think there would be huge disappointment if it were ever really embraced by the mainstream, because it would have ceased to be that rebellious other that people perhaps need.

Being an alternative is part of the attraction?

Yes. There is a version of this that wants to talk about more spiritual factors and quantum factors and things that I don't even particularly understand. It pushes beyond even a naturalistic frame of reference and begins to make what I would consider paranormal claims.
Some aspects of this might get mainstream, and then there will be people who would push it back out again, challenging a view of ourselves that places limits on ourselves.

A view of ourselves that sees us just as bodies or physical things?

I think so. There is a version of mind-body medicine that sees healings that may or may not be possible as evidence that we're capable of far, far more than those narrow-minded medical doctors or scientists are prepared to see.


Ron Mead said...

Harry, your Harrington link doesn't appear to lead to a relevant article.

I'm a prostate cancer survivor and an active member of a prostate cancer support group on Sydney's North Shore.

Let me tell you that support groups have an enormously positive effect on patients, especially newly diagnosed cancer patients. Many medical specialists, while amazingly skilful in their specialities, are often not good communicators.

We find that when new patients arrive at our group what they are seeking in information, as well as the solace that comes with talking things over with those who've "been there, done that". We get lots of questions like "is what I am going through now, two weeks after my radical prostatectomy normal for this stage?" The answer is often along the lines of "what happened in my case two years ago" We don't pretend to extend life except perhaps to guide men and their wives in the best ways of seeking and obtaining proper professional attention, whether that relates to managing side effects like incontinence, erectile dysfunction, and sometimes depression and difficulty in their relationships. We are not doctors and we deliberately refrain from giving medical advice.

Some people studiously avoid support groups, preferring to move on after their treatment and that is a personal decision. But I'm very heartened when I hear a member of our group tell me well after his crisis has passed how incredibly valuable the group has been to him and his wife in his journey through cancer.

I have to say that I'm appalled by the negativity one hears about support groups from people who've never experienced hearing those devastating words "I'm sorry to tell you, but you have cancer"

hc said...

I'll try to retrieve the link - it is now behind a subscription paywall.

You are right - people can feel better but does it provide a cure? I don't know. as I point out in the post skeptics cannot sensibly endorse the efficacy of placebos in certain situations that operate via the power of suggestion and then reject non-conventional treatments elsewhere.

Ron Mead said...

Harry the point I was trying to make is that support groups cannot and do not claim to "provide a cure". That's not their function, never has been and never will be. They shouldn't be viewed negatively because they don't perform what they were never set up to do.