Review: Cure, by Jo Marchant
Cure: A Journey into the Science of Mind Over Body, is an excellent new book by science journalist Jo Marchant, which explores the healing (and harming) power of the mind and emotions over the body. It succintly brings together a lot of recent evidence in areas sometimes dismissed as 'pseudoscience', such as the placebo response and hypnotherapy, to argue for their medical efficacy and the need for a medical model which better incoporates the mind.
Marchant argues: 'Conventional science and medicine tend to ignore or downplay the effect of the mind on the body. It's accepted that negative mental states such as stress or anxiety can damage health long-term...But the idea that the opposite might happen, that our emotional state might be important in warding off disease, or that our minds might have 'healing powers', is seen as flaky in the extreme.' Her book succeeds in its aim of rescuing this area 'from the clutches of pseudoscience'.
The book is very much in line with a new research project I'm involved with at the Centre for the History of Emotions, calling Living with Feeling, which also explores the interaction between emotions and health. I'm going to summarise the main points from each chapter of Marchant's book.
Chapter One looks at the placebo response, in which fake or dummy medicine still has real healing effects on patients. Mainstream science has tended to dismiss the placebo effect as a trick or mental anomaly that mainly works for 'unintelligent or inadequate patients', as The Lancet put it in 1954. In fact, the placebo response has been shown by researchers such as Fabrizio Benedetti to have powerful physiological effects. For example, Jan Stoessl, a neurologist at the University of British Columbia, found that dopamine levels tripled when patients with Parkinson's were given placebo pills. Fabrizio Benedetti has used brain scans to identify the effect of placebo - the effect of belief - on motor neuron cells, which fire more slowly in Parkinson's sufferers following a placebo. The power of belief and suggestion appears to release natural healing chemicals in the brain such as endorphins, which help counteract some illnesses like Parkinson's and MS, as well as psychiatric illnesses like depression. Indeed, another placebo researcher, Irving Kirsch, has suggested wonderdrugs like Prozac work mainly through the placebo effect - his book The Emperor's New Drugs explores this. Benedetti has also found that valium 'has no effect unless patients know they are taking it', which surprised me.
Chapter Two explores how placebos even work when patients know they are taking a placebo. A 2010 study by Harvard's Ted Kaptchuk - a leading researcher in this field - gave placebos to patients with Irritable Bowel Syndrome (which affects 10-15% of the population) and told them 'that although the capsules contained no active ingredient, they might work through mind-body self-healing processes'. They did significantly better than those who received no treatment. Marchant highlights the market in 'open-label placebos' like Placebo World, Universal Placebos and Aplacebo - the latter set up by Simon Bolingbroke, who manages his own pain from Lyme disease using placebos. 'It sort of started as a joke', Bolingbroke says. 'But it's a joke that's real.'
Marchant deepens her analysis of the placebo effect in this chapter, exploring the power of 'feeling cared for' - patients who receive their drugs when their doctor is present apparently get 50% more pain relief. She suggests that placebos tap into 'ancient evolved pathways' in our brain which persuade our brain 'that we are loved, safe and getting well'. She also begins to explore the connection between placebo, ritual and symbols - bigger placebo do better than smaller ones, two pills work better than one, coloured pills work better than white, blue helps us sleep, red is better at relieving pain, green is better for anxiety. 'We are symbolic animals', says Benedetti. We're also ritualized animals, and the ritual interaction between healer and patient affects the placebo response. 'Words, gaze, silence, body language, all are important', says Kaptchuk.
In Chapter Three, Marchant explores another mechanism for the placebo effect - physiological conditioning. She writes about the relatively new field of psychoimmuneology (which includes QMUL's Fulvio D'Aquisto), which has proved that our autonomic nervous system is connected to our immune system, and that the placebo effect (or beliefs) can impact immune cells through neurotransmitters. She writes about a new medical intervention called Placebo Controlled Drug Reduction, where patients are given a drug in combination with a placebo, and then subsequently the drug is reduced while the placebo remains. The physiological association between the drug's effects and the placebo's effects means the placebo keeps working - a 2010 study by Adrian Sandler found PCDR to be effective in treating children with ADHD.
Chapter Four covers the highly contentious area of fatigue and Chronic Fatigue Syndrome. Marchant explores how fatigue used to be understood as an automatic physiological response, but which some researchers argue is actually more like an emotion. Sports psychologist Tim Noakes of the University of Cape Town has 'proposed that the feeling of fatigue is imposed centrally, by the brain'. A 'central governor' in the brain makes us feel tired before our body gets damaged, as an early-warning system, Noakes argues. However, the central governor can get it wrong, and can be modulated through training, and through belief - Chris Beedie at Aberystwyth University found cyclists given a pill they believed was performance-enhancing could cycle 2-3% faster.
Marchant then highlights the research of QMUL's Peter White on Chronic Fatigue Syndrome. White's research argues that CFS can be treated with a combination of Cognitive Behavioural Therapy and Graded Exercise Therapy. A 2011 study found that 22% of patients recovered after a year of CBT and GET, while patients trying 'adaptive pacing therapy' (in which you adapt to the new circumstances of having CFS) did no better. CBT and GET appears to be a way to re-train the 'central governor' of your brain when it gives you the false information that your body has reached its fatigue limit. The suggestion that CFS involves the mind is, however, hugely unpopular with some sufferers of ME (Myalgic Encephalopathy, patients' preferred name for the condition) , who have been stigmatized for decades as suffering from 'yuppie flu' or 'Raggedy Ann syndrome'. A Guardian article by Marchant on CFS has already attracted the ire of ME groups. Perhaps it's the mind / body paradigm that's at fault - it's rarely just the mind or just the body, but a complex interaction between the two.
Chapter Five looks at hypnosis, a medical intervention with a chequered history ever since Benjamin Franklin's 1784 trial of Mesmer's animal magnetism dismissed it as 'imagination'. The Lancet was initially a fan of John Elliotson's early research into animal magnetism in the mid-19th century, but then rapidly and publicly dismissed it as mere 'suggestion'. But can suggestion still be very healing? Part of the problem is there is still argument over what hypnosis actually is and what it does. On one side are those who argue it induces a hypnotic 'state' in the brain - a trance or altered state. On the other side are those who argue it is simply role-play, people going along with suggestions, particularly if given by a high-status figure. It's probably both. In support of the 'state' theory, neuroscientist David Spiegel has found that brain scans of people hypnotized to see black and white as colour show the colour-processing parts of their brain are activated - if this is just 'make-believe', then it's make-believe at a neurological level.
Marchant highlights the research into the healing power of hypnotherapy visualization for sufferers of Irritable Bowel Syndrome, which helps 70-80% of IBS sufferers, according to the research of Peter Whorwell. Visualizing and imagining apparently affects our physiology - a study by Karen Olness found that children who imagined heat going to their hands really did heat up their hands. I find that fascinating, considering the importance of 'warm healing hands' in charismatic Christianity and alternative medicine. It also reminds me of how people using Tibetan Tummo meditation manage to heat up their body, and even endure ice baths for long periods, by visualizing a candle burning in their chest.
Chapter Six takes this idea of the healing power of visualization into the realm of virtual reality, by exploring a VR programme called Snow World, which has been found to help burn victims to cope with pain, apparently by distracting them with an interesting immersive world. VR can also be used to manipulate people's body awareness, mitigating the symptoms of phantom limb syndrome, and even inducing out-of-body experiences. Below is a video on Snow World:
Chaper Seven deepens the analysis into the importance of caring relationships in healing, showing how mothers giving birth who have the same care-giver helping them throughout the birthing process tend to have less complications and easier births - an important finding when one third of women feel traumatized by birth. Marchant also looks at the use of Comfort Talk by medical practitioners. She takes up the importance of caring relationships in Chapter Ten as well, highlighting the Tecumseh research project, which explored the importance of social connections to the immune system.
Chapter Eight looks at how stress is bad for our immune systems and even ages us, and how growing up in poor, rough neighbourhoods affects our bodies. Stress is apparently connected to our imaginations too - we remember past adverse events and expect them in the future, so our bodies are stuck in defense mode. Chapter Nine looks at how we can counteract this with mindfulness, bringing our mind back to the present moment rather than worrying about the past and future. Marchant also discusses the Relaxation Response, first highlighted by Herbert Benson, who looked at how chanting a mantra (or any word, it doesn't have to be Hindu) helps kick in the parasympathetic nervous system response, enabling our bodies to relax and heal.
In Chapter Eleven, Marchant looks at the role of the vagus nerve as an important transmitter between our mind and body, particularly through Heart-Rate Variability (HRV). Those with higher HRVs are apparently better able to adapt and respond to adverse events. We can modulate the HRV through techniques like meditation, and train our response through biofeedback mechanisms - in one app, for example, as your HRV goes up, you see on an image change and the sun rise over a tree! That kind of live feedback makes training much easier. Marchant also looks at the ground-breaking research of Kevin Tracey into Vagal Nerve Stimulation, using implanted electric nerve stimulators which are controlled via iPad. It's been found to be helpful in treating arthitis, MS, depression and other disorders. Is electric healing the future? One more device to charge!
Finally, Chapter Twelve brings these various strands together to look at the role of ritual, care, belief and faith in healing at Lourdes. Marchant visits Lourdes and takes part in the healing ceremonies. Despite her atheism and skepticism, she is struck by the physical power of the ritual, and the deep caring connections that visitors feel. 'Quite unexpectedly, I feel a powerful sense of connectedness, as if I'm at the centre of something much, much bigger', she writes. Exeter's Paul Dieppe, another key researcher in this field, has also studied the Lourdes effect - I interview him here.
But do visitors to Lourdes experience 'miracles'? Maybe, maybe not, but it certainly unlocks many of the healing responses Marchant's explored throughout the book. She also highlights the healing power of spiritual beliefs in HIV patients - a 2006 study of HIV patients found 50% throught their religion / spirituality was helping them live longer. Another study found that 45% of HIV patients became more religious after their diagnosis, and those who did 'lost CD4 cells much more slowly' over the four years of the study than those who didn't. Religious belief isn't always healing - those who believe in an angry or judgemental God are more stressed and heal less well.
Marchant concludes by noting the scientific community's 'ingrained resistance' to much of the research she has explored, how difficult it is for the researchers to get funding, how the NHS website still says 'there is no strong evidence' for hypnotherapy's effectiveness for IBS, when there actually is. She puts this down to the success of the materialist paradigm in giving rise to modern medicine, in which the physical is taken as real and measurable, while the mental / emotional / subjective is seen as slippery, hard to measure, and best ignored. As a result, we put much more faith and funding into surgical or chemical interventions than mental ones, despite the huge cost of drugs which may work mainly through the placebo effect, and despite the sad fact that half a million people die each year in the western world accidentally through psychiatric drugs. We have replaced spiritual healing with chemical healing, even though the latter is still, to some extent, a faith-system.
We need to go beyond the mind / body split and find new terms, like 'psyche', or mind-body continuum, or even the dreaded 'holistic medicine', particularly in the treatment of chronic conditions like IBS, CFS, MS, and depression. It reminds me of meeting Professor Qasim Aziz, head of QMUL's gastroenterology unit and an expert on IBS, last month. He told me that, although it is now official NHS policy to combine mental and physical care within hospitals, in reality this isn't yet the case at all, and many IBS sufferers are passed from department to department without proper treatment, until around 40% contemplate suicide, and some go through with it. I hope this changes, and we can reincoporate the mind into medical care. This excellent book is a hopeful step towards that change, and essential reading for those interested in the medical humanities and the fascinating interplay between belief, meaning, imagination, emotion, ritual, relationships, and our material bodies.