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.