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The healing power of the doctor-patient bond
May 3rd, 2011
11:47 AM ET

The healing power of the doctor-patient bond

Dr. Charles Raison, CNNHealth's Mental Health expert and an associate professor of psychiatry and behavioral sciences at Emory University, writes regularly on the mind-body connection for better health.

Hot-off-the-press studies that have exciting new treatment implications always cause a media stir, as well they should. But I find it equally exciting to discover older studies with huge treatment implications that were overlooked when they first came out, either because they went against the scientific grain of the time, or because no one stood to gain financially from their findings.

To complete the little triptych of hope that started with my blog on optimism and heart disease and continued with the power of placebo to enhance health, this week I want to talk about what a number of older, and little known, studies show is probably the most powerful tool in our arsenal against depression, which must certainly be the world’s No. 1  killer of people’s ability to access the types of hope that promote health and well-being. Any guesses as to what this tool might be?

Let’s go back in time almost 30 years, when psychiatry was still in the first heady flush of excitement over the power of antidepressants, and a hot topic of the day was how well the much older mode of treatment -  psychotherapy -  might stack up against medications.

To address this issue the National Institute of Mental Health launched a huge investigation that directly compared the efficacy of two types of psychotherapy (cognitive behavioral and interpersonal)  with a (now old) antidepressant called imipramine, while simultaneously comparing these active interventions with a placebo. After randomizing several hundred depressed individuals to one of these interventions, researchers followed them for five years, which, sadly, is the best long-term study on the treatment of depression that has ever been done.

The study found - not surprisingly - that medications and therapy are superior to placebo. But here’s where things get interesting. In a sub-study of the larger project, researchers videotaped doctor-patient interactions during clinical visits and then showed these videotapes to expert raters charged with the task of assessing how good the relationship was between the doctor and patient, based solely on what they heard and saw on the tapes.

Remarkably, just by watching the tapes the raters were able to make strikingly accurate predictions regarding who would go on to get well and who wouldn’t, regardless of the treatment they were receiving. In fact - and this is the really amazing thing to me - having a good therapeutic relationship between doctor and patient turned out to be a more powerful in promoting recovery from depression than whether one got an active treatment or placebo. Especially powerful was how the patient felt about the doctor.

Patients who showed a strong and positive emotional connection with their doctors were far more likely than others to improve during the study. But what the doctor felt and believed was also important. Indeed, over and above the quality of personal relationship with the patient, if a doctor believed that the patient would improve, he or she was more likely to do so than if the doctor did not radiate this type of positivity.

These findings have been replicated many times over in the intervening years, really highlighting the simple, and totally believable, fact that a patient’s relationship with his or her clinician can be itself a powerful source for sickness or healing.

By the way, this doesn’t just hold for depression. Similar patterns are known to occur in the treatment of almost every imaginable disease, mental and physical. If researchers discovered a medication with this much therapeutic power it would be huge news and earn untold billions per year in profits.

The implications of these findings are simple enough, if not always so easy to implement. For us doctors, the message is that anything we can do to bond with our patients and provide hope and confidence will translate into huge improvements in our clinical results, regardless of our area of specialty.

For us patients, the message is that the onus in on us to keep at it until we find a clinician we can trust and believe in, and who makes us feel as hopeful and inspired as possible given our current state of health.

The onus is also on us to balance this quest with caution about - as Barack Obama so famously said - not letting the perfect be the enemy of the good. Studies show that very perfectionist people tend not to be able to establish positive therapeutic relationships with their doctors, perhaps because no one can be perfect enough for them. This failure explains a large part of why perfectionism is so strongly associated with poor therapeutic outcomes in depression.

If we take my last three blogs in toto, the evidence is very clear that hope heals, not perfectly, and not completely, but with enough power that harnessing its effects is one of the most effective strategies available to us as patients or clinicians. Hope, optimism, a sense of warm personal connection with our clinician - these are all inter-related factors that  tend toward one end, which is to put our brains and bodies into physiological states most likely to promote healing.


soundoff (24 Responses)
  1. Michele M

    This is soo true!!! I absolutely agree with the doctor that wrote this 100%. Even if your doctor is being negative, you have the power to control what you think and you can prove them wrong. A lot of the healing process is more than just physical; the emotional aspect is the part that will get you through whatever it is that you are going through. If you emotionally give up your body will soon follow. It's like working out, people complain and "think" they can't handle something and will probably give up quickly. The people that have their mind-set, even if they're dripping sweat and barely breathing will make it through even if they struggle until the end. Mind over matter 🙂 Once your mind is in the right place, the rest will usually follow, even if that means you will never be 100%.

    May 3, 2011 at 12:59 | Report abuse | Reply
    • charles s

      What this article states is absolutely true. How you feel towards your doctor is a key indicator to how well your treatment will go. I especially remember having a doctor who was angry at me and how he treated me. Do not ever let an angry doctor treat you or you will be sorry. This particular doctor became angry at me because he insisted that I had missed an appointment time to have a mole removed. I produced the appointment card and showed it to him. He agreed to remove the mole and his action inflicted pain on me because he did not let the local anesthesia take affect before operating. I should have reported him to the clinic but was intimidated by his action. Never again would allow a doctor to treat me that way.

      May 3, 2011 at 23:42 | Report abuse |
    • K

      I'll second what Charles said. I had a doctor who, for some reason, didn't like me, and flatly refused to consider that he had misdiagnosed when the prescription didn't help. Accused me of "not wanting to get well" instead of changing the prescription to treat what I really had. All he wanted to do was verbally abuse me, not help me, so it's no wonder that I got sicker without appropriate treatment.

      May 4, 2011 at 03:58 | Report abuse |
    • David

      Great article and I'm glad I stumbled onto this. Really some good insight into the client/clinician relationship and something I'll definitely be more aware of in my own practice.

      Cheers,
      David
      http://www.allthingsdepression.com

      May 4, 2011 at 15:20 | Report abuse |
    • Real

      It depends. Talking with your faimly doctor and letting him or her know what you are feeling is a good place to start. Then, they may suggest a therapist and prescribe medication for you, or suggest a psychiatrist. Every person and every situation is different. Depression is very serious, and you don't have to suffer. Talking with your doctor seems like a good place to start. Hang in there..hope this helped.

      July 1, 2012 at 05:00 | Report abuse |
  2. Bobby

    American Medicine is big business.. The goal of our Medical Establishment is to make money, not cure patients.. So in choosing your doctors and therapy, the old proverb rings true.. " Let the Buyer Beware".. Best to do a lttle resarch on your own, Drs are not always familar with treatments outside the standard pharma-medicines..It is a shame that Americans have to avoid their Drs when looking for more natural-holistic treatments with few side-effects. Drs need to be re-educated..

    May 3, 2011 at 14:11 | Report abuse | Reply
    • Mike

      No, I'm sorry, but you're twisting the message of the article into something it's not. The article is not decrying the use of pharmaceutical treatments and extolling "natural-holistic treatments" (also known as overpriced placebos with no scientific validation). It's simply highlighting the importance of a good physician-patient relationship affecting a patient's actual well-being. Please, don't use this as an avenue to peddle snake-oil to the people. Most Americans are smart enough to know where they need to go when they get really sick.

      May 3, 2011 at 14:41 | Report abuse |
    • Pat

      I agree with Mike.

      May 3, 2011 at 15:06 | Report abuse |
    • cara

      Bobby, you too have been inculcated- by just another very powerful and profit-driven industry - the holistic movement. No one argues that healing comes in many forms. But don't knock western medicine. It's brought you better health than 99.9% of the humans who have ever walked the earth.

      May 3, 2011 at 17:51 | Report abuse |
  3. DAN

    I am a Doctor of Internal Medicine. I provide high quality, evidence based medicine to my patients. I work for a local hospital. I am constantly being pressured to see more patients in less time. Even though I provide much better care for my patients, the only thing that my employere wants is to see more patients in less time. High quality medicine takes time. The medical insurance companies and large hospital owned practices are ruining medical care in this country. Keep this in mind the next time you see your doctor for a cold and have to wait an hour to be seen and have only a few minutes face time with your doctor and they throw an antibiotic at you just to get you out of the room. Not to mention that they might miss diagnosing you with diabetes or high blood pressure, or neglect to schedule you for a preventive physical. Sounds encouraging, right? Sadly, it happens all too often.

    May 3, 2011 at 17:10 | Report abuse | Reply
  4. Rob

    As a family physician, I agree with Dan; it is increasingly difficult to practice the type of medicine that maximizes the value of the doctor-patient relationship. It is still possible to do this, but you have to buck the system and resist all the pressures and disincentives. The invidious corporate ethos has invaded medicine to the detriment of health professionals and patients. I don't know if a government sponsored single-payor system would improve the situation, but it certainly could not make it worse. I have a much better experience with Medicare and Medicaid than with the typical insurance company.

    May 3, 2011 at 19:04 | Report abuse | Reply
    • charles s

      Rob – do the best you can and treat your patient with respect. It is too bad that the practice of medicine is so driven by corporate greed.

      May 3, 2011 at 23:47 | Report abuse |
  5. Charmaine

    I suspect the patients that recover faster based upon a positive doctor-patient relationship is because patients want to feel like someone really CARES about them . This helps them feel good about themselves thus speeding recovery. The desire to reciprocate behavior is quite strong in humans. If someone cares about us (the doctor) most people will want to return the favor and "repay" the doctor by getting well, or at least trying to show progress by following the proscribed treatment. This elicits a favorable response from the doctor thereby continuing the patients desire to show improvement.

    May 3, 2011 at 22:29 | Report abuse | Reply
  6. DP

    The problem also stems from the cost of medical school...you have an average indebtedness of doctors from medical schools of around $170,000. So for physicians not to want to see as many patients as possible puts them at risk of losing their job and then losing income in order to pay those loans back. Its a horrible truth but as a future medical student its a heavy burden on my mind. I can tell everybody hear that I really want to help the patients...but I believe physicians do hold in the back of their mind that mentality to survive and pay back loans they may have incurred. I believe if medical schools can somehow make tuition cheaper it may help lessen some of the burden on the healthcare system. But I do believe in the power of a positive clinical relationship as many studies have shown that effective communication between physicians and patients is essential to a successful clinical relationship. It shudnt have to be a burden on both parties involved.

    May 3, 2011 at 23:04 | Report abuse | Reply
    • charles s

      In my state, the public university is under constant attack by the Republicans who control the legislature. This university is the primary provider of doctors for the state. I really believe that if the doctors in the state were to talk to their legislators that they would have a better chance of being heard than average citizens. All students at the public university are having a terrible time because of constantly increasing tuition. The increasing tuition is forcing more lower income student out of college and the long term cost of these increases will be a great burden upon our society.

      May 3, 2011 at 23:54 | Report abuse |
  7. Jose Btesh

    I do not belive most of Drs. are doing a good job. Most of them agree with the commercial medicine lead by corrupt labs trying to sell medicine ( legal drugs) instead of teaching to prevent. Medicine in this country, in my opinion is like going to the mall; buy the magic pill and come back for blood. Food is horrible, starting at schools, and Drs have little time to bond-connect with patients ( we have to be very patient) as insurances require dozens of forms and paperwork to complete. My Dr. writes on the computer while talking to him, instead of looking my eyes, and this happens in the different areas of medicine.
    USA has the worse medicine in the first world countries, sad, very sad

    May 4, 2011 at 00:54 | Report abuse | Reply
    • disagree

      Jose, I'm sorry that you have had a bad experience, but let's not paint with a broad brush. I have three excellent doctor's who take the time to talk with me and find out what's going on in my life that may be affecting me physically. They are curious and well-informed. They will come up with a plan with a few options, and we try them until we find the best outcome. I don't feel hurried or dismissed in the slightest. All of my doctors know my history quite well and interact, and two of them I only see once or twice a year, yet they are completely up-to-date.

      Our school system has a low-fat, low-sugar, low-sodium menu. We have no fried foods (except ala carte options for high schoolers), and everything is baked. We keep the bread content as low as possible and offer fresh fruits and vegetables every day. We offer no ice cream or sugary snacks to elementary school students, and we give a free fruit & veggie snack to our 5 most economically challenged schools. It is quite a healthy menu.

      I have to disagree that we have the worst medicine of first world countries. Can we improve? Yes. Do we have serious problems, especially with insurance companies? Yes. Doctors are often caught in the middle and just trying to do the best that they can. And, no, I am not married to or even related to a doctor or anyone in medicine. This has just been my life experience. I'm sorry that yours was not as positive.

      May 4, 2011 at 07:18 | Report abuse |
  8. Cilla Mitchell

    Or, some doctors do not bond with their patients at all and just forget about them. The doctor who forgot about this patient is now practicing at a NY Clinic, thanks to The Texas Tort Reform Act.

    Google Cleveland Mark Mitchell, and click on youtube.

    May 4, 2011 at 06:20 | Report abuse | Reply
    • Axe to grind??

      Wow, Cilla, are you the ex-wife? Sounds like you have a personal axe to grind.

      May 4, 2011 at 07:06 | Report abuse |
  9. Cilla Mitchell

    You didn't watch the video. You just don't get it, do you?

    May 4, 2011 at 07:30 | Report abuse | Reply
  10. The_Mick

    Physical success in health mirrors the "coach" effect in sports where it has been said: 50% of the art of coaching is knowing there's more than one possible method but making your athletes believe your way works. I had a poor PCP, in terms of looking for the causes of symptoms, getting back to me with info, etc. for a few years until my sister-in-law found the superb PCP I now see and about whom my sister, a nurse, says is "sent from heaven." When he recommends a medicine or a procedure or a particular specialist I'm very comfortable that he's providing excellent care and that kind of trust is important in motivating the patient to do as the doctor says.

    May 4, 2011 at 07:43 | Report abuse | Reply
  11. Jorge

    Whomever thinks that the pervasive emotional state is not instrumental in the physical healing process has never been really ill or chronically sick. Every doctor knows how determinant the though/emotional process is to endocrine and immune system function. The body alters it's processes to adapt to repeated or anticipated behaviors all the time and when confronted with a defeatist, depressed or decompensated mindset, will go into economy of effort mode and react poorly to health threats. Doctors who do not understand this or are unwilling to acknowledge and address this are not truly at the top of their game.

    May 4, 2011 at 12:34 | Report abuse | Reply
  12. Anonymous

    "Patients who showed a strong and positive emotional connection with their doctors were far more likely than others to improve during the study."
    Dare I say that this requires a professional and ethical doctor. It is sad that some doctors take this to the extreme and enter into relationships with patients which actually causes much more harm than good.

    May 4, 2011 at 13:55 | Report abuse | Reply
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