photo by Garry Simpson
by Andrew DeCanniere
Last month, I had the opportunity to speak with Jo Marchant, author, most recently, of Cure: A Journey Into the Science of Mind Over Body (Crown, 2016) — one of the most engaging and informative books I’ve read this year — which provides an in-depth, eye-opening look at the mind-body connection. Read on to see what she has to say about what inspired her to write the book, the placebo effect, the dichotomy that exists in terms of how society tends to view the mind-body connection, tools and techniques that show real promise as alternatives —or, at the very least, supplements — to drugs, the importance of social networks and much more.
UR Chicago: Where did the idea for the book come from?
Jo Marchant: It came about quite gradually, just because there were a few things that I had a natural interest in—like the placebo effect. That has always really intrigued me. As a science journalist, I ended up writing about placebos and the placebo effect a lot. You come across it in clinical trials all the time, and I’ve always wondered what’s going on there.
First of all, if placebos can make people feel better, why are we just trying to eliminate that in clinical trials? Why isn’t there more effort going into actually trying to make use of that? Secondly, if they do work, why do they work? Why would a fake treatment make you feel better? That’s always intrigued me. I’ve always thought that hypnosis is kind of interesting as well. It’s another subject where there are these glimpses of something really interesting going on with the brain that we don’t really understand, but it’s hard to find good, solid, scientific trials that deal with it.
Then, I ended up writing a piece about mindfulness and depression for Wired magazine, and again I was fascinated by that subject. I just realized that these three topics all had something in common, I suppose. That was when I first started thinking about this as a topic for a book. Again, in all of the books I’ve written, I’m interested not just in the straight science, but science where there’s a sort of sociological and philosophical angle to it as well—where there are personal stories to tell and where human assumptions and agendas end up feeding through into the science. So, all of that I suppose.
UR: One of the things I found really interesting is this dichotomy in how society views the mind-body connection: a science-based approach on one side and a more mysterious perspective on the other.
JM: That’s one of the things that attracted me to the subject. It’s a very polarizing question. You do have the alternative healers on the one side who are convinced that it plays a fundamental role in health, and often you have the claims of miracle cures. You know, it’s not really based on science. It’s just this feeling that the mind is some sort of magical, mysterious healing power. On the other hand, you have the skeptics who tend to be more conventional scientists, proponents of evidence-based medicine who, at the extreme end, will argue that the entire idea of healing thoughts is deluded and that the mind plays no role in health.
The whole discussion tends to get split between those two extremes, and that did interest me. I wanted to look at the science, and see what the research really tell us, because neither of those extreme positions made much sense to me. It’s surprising—even now that I have written the book—that making any suggestion the mind might play any role in health, I get people responding almost as if I’m sort of automatically advocating that we throw out all of Western medicine and don’t need physical drugs or treatments anymore. It just seems to be that you get pushed to one extreme or the other.
People seem to find it hard to accept there’s a middle ground—that the mind might play a role, but we still need the physical drugs and treatments. My message really is that we can study the mind in a scientific way, and that we should be trying to use the two approaches—physical and psychological— together.
UR: It’s amazing how effective a placebo can be—even when people know it’s what they’re taking.
JM: I was surprised by a lot of the research about placebos. Seeing these biochemical pathways that are very similar to the ones that are triggered by drugs—that was really interesting and surprising to me —and the size of the effects, as well. They vary an awful lot.
Not everybody responds to placebo, and in some trials you might have no one who responds to placebo. In other trials, you might have everyone responding. It’s very variable. It’s not that everybody responds dramatically, but there certainly are cases—like some of the people I spoke to in the book—who did have very large responses to placebo. Just the fact that, in general—when we take a painkiller, for example—across the trials that I looked at, between one-third to two-thirds of the benefit that we get from that painkiller isn’t down to the direct biochemical effect of the drug at all. It’s down to our placebo response to that painkiller. That really surprised me, knowing that’s what’s happening every time we take drugs.
As you say, with the honest placebos as well—where people know they’re taking a placebo— I think that’s been very surprising to the researchers working on this as well. There are possible reasons for why that would make sense. Social interaction, for example—just that experience of being cared for seems to be important in placebo responses. If you’re taking part in a trial and being given a treatment and seeing the nurse every week—or however often it may be— just that care you’re receiving may be important for triggering responses, even if you know that the actual treatment itself isn’t real.
There also are the conditioning processes, where the body learns the appropriate physical response to the drug and then, later— when you take a placebo that looks the same— your body automatically triggers that same physiological response. Those learned associations happen regardless of whether we know it’s a placebo or not. They’re automatic. It’s like Pavlovian conditioning. Again, that’s probably something underlying a lot of the placebo responses we experience.
UR: Another thing you touch on is the way medical professionals communicate with patients and the very real impact that can have.
JM: There’s interesting work to be done in looking at the words that doctors use. How can doctors communicate about side effects in an ethical way—you want to be honest and ethical about drugs that are being prescribed—but without unnecessarily triggering these negative expectations. I think that’s going to be quite an interesting line of research, looking at the attitudes of doctors and the words that they use, along with how this information can be conveyed in an ethical way that also tries to maximize the outcome for patients.
UR: I’m sure doctors generally want their patients to be informed but, on the other hand, you don’t want them expecting the negative side effects or complications.
JM: And that comes in for things like surgeries as well, where patients are conscious for the procedure. There was a study done looking at the wording used by staff. When they say ‘This is going to sting a bit,’ if they’re giving an injection or something—or even if they say things like ‘This isn’t going to hurt too much’—just that very mention of pain, hurting or stinging causes the patient’s pain to jump right up.
That same team has been doing work looking at changing the language that medical staff use to remove all of those mentions of how much things are going to hurt, and using more neutral language instead. So, telling patients before the surgery—during the informed consent bit—about what might hurt and what might not, but then when they’re in the operating room they don’t use words like ‘sting’ or ‘burn’ or ‘hurt’ or ‘pinch,’ making it more neutral. That does seem to be really helpful in terms of reducing patients’ pain during the procedure.
UR: You also discuss the relatively limited choices faced by women giving birth today — either at home, where they might not have access to care, or at the hospital, where they are very quick to engage in various interventions that may not be necessary.
JM: Well, it’s that polarization again. They’re being pushed to one extreme or another, where you can have the high-tech interventionist care in the hospital or, if you want that human support, then you have to forgo that access to intervention. I definitely think that this isn’t about rejecting high-tech interventions, but that we should be able to have the best of both worlds.
UR: With opioid use at an all-time high here in the U.S., you mention virtual reality technology as a potential substitute or supplement for some drugs.
JM: You’re right. Opioid use is at an all-time high in the U.S. at the moment. I think that, at last count, it was 16,000 Americans dying each year from overdoses of prescription painkillers. So, it’s huge. I think that the CDC has called it America’s worst-ever drug epidemic. It’s really a big problem, and it highlights the downsides of drugs—the side effects, the addiction.
What all of this research—the placebo research, the virtual reality research—tells us is that the brain plays a really big role in creating and controlling the pain that we experience. Pain is not purely some physical and pharmacological issue. It’s affected by psychological factors, social factors, cultural factors. For example, stress makes us more sensitive to pain, and there are lots of ways to treat pain. It’s not particularly helpful—particularly with chronic pain—to be treating that purely with drugs.
With virtual reality, that’s based on the idea that the brain only has a limited capacity for conscious attention. If your attention is being grabbed by something very immersive and compelling—like this virtual reality ice canyon—then there is less attention left over for the pain. In trials, it does seem to ease patients’ pain by up to 50 percent, in addition to the pain relief they’re getting from the drugs. I think that, again, that’s an example of how it’s not an either/or. You’re not throwing out the drugs. You’re using psychological techniques to give you that extra pain relief on top of the drugs, because you’re limited with the drugs in terms of the side effects and what dosage you can prescribe for people. The other thing that research tells us is that this isn’t just about dialing down the pain of a mild headache. These are severe burn patients, undergoing some of the most severe pain in medicine.
During these wound care sessions that they have to undergo, they’re having the dead tissue scrubbed out of their burns. Later on, they have physiotherapy, where the scar tissue has to be literally torn to make sure that they still have range of movement as they heal. So, this is incredibly agonizing, even when they’re taking the highest safe doses of drugs.
Patients often say that that it’s more painful than being burned in the first place. This is really severe, serious pain, that even on the highest safe doses of drugs, they’re not able to control the pain for these patients. Things like ‘Snow World’ are helping to add to that pain relief then, when they can’t go any higher with drug doses. I think this is going to be a really interesting area of research, particularly because virtual reality is about to explode.
You’ve got the Oculus Rift headsets that are available now. So, this idea of having these portable headsets that you can plug into your smartphone is going to be commonplace. That’s really putting this immersive virtual reality into the hands of a lot of people, and it’s also going to drive development of more and better virtual reality worlds. People will have more choice of the worlds they want to go into but also, as you can’t be in virtual reality all of the time, I suppose the research also just shows the power of distraction and mindset in pain. When I ask researchers about advice for people who are in chronic pain, they say that just things like going out for a walk, engaging with other people, doing things that are meaningful all help to alter brain activity, change our attitude and our mindset, and help to reduce pain.
UR: As, it would seem, do hypnosis and meditation. They too seem to be particularly effective in terms of pain management as an alternative or supplement to drugs.
JM: I think hypnosis is really intriguing and it does seem that there is something going on in the brain. You get effects on brain activity and physiology that you don’t see in people who aren’t hypnotized. On the other hand, scientists don’t understand exactly what’s going on when we’re hypnotized. In a lot of areas, the research isn’t really that strong, so you get claims of hypnosis curing warts, for example, and having all these various clinical benefits, but the trials are quite small and are not repeated.
That’s why I focus on Irritable Bowel Syndrome, because the research is quite strong. There are clinical trials from different teams from around the world that have been repeated and you’re getting quite strong results in meta-analyses. It does seem that a course of hypnosis can reduce the sensitivity of the gut to pain in these patients, and also that they can control or influence the rate of gut contractions—which is not something that is usually under conscious control.
So again, more research is needed there, but that’s definitely a very interesting area of research. Meditation, again, is showing that mental state does seem to have a big effect on pain. Rather than anesthetizing pain, in mindfulness I think the idea is to sort of embrace the pain, to accept it and invite it in, and to try to remove the negative emotional content of the pain. You still feel the pain, but it’s not distressing you as much. That does seem to be very helpful for people.
UR: Another topic in the book is this idea of how your environment influences your health.
JM: So the research is still at quite an early stage here, but it does seem as though your environment in very early life your first few years of life—is critical in determining how you will respond to stress throughout the rest of life, therefore feeding through into your risk of chronic disease. Even if somebody does really well in school and they get a good job, leave and lead an affluent lifestyle, they’re still going to have that worse health as a sort of legacy of their very early years in adversity.
There seem to be a couple of mechanisms of that. One is just the effect on the development of the brain and the structure of the brain. So, you’re actually left with a brain that is more hyper-vigilant and response to threat. Then, the other mechanism seems to be through epigenetic changes that our patterns of gene expression and the immune system are just sort of set, so that the immune system is sort of hyper-sensitive and responding more strongly to stress. Some of this work is coming from animals—so there’s very good direct evidence for this in animals—and then the work in humans has to be more observational, less direct. If you take all the research together, there’s quite a compelling picture that’s coming together there.
UR: All the more reason to address inequality in society.
JM: I think it makes this a really political issue, because there are swaths of the population who are being condemned to worse health throughout life — as I say in the book — before they are even out of diapers. Clearly, that is just not fair. They don’t have the opportunity to get out of that. Even if you do escape, from an economic perspective, you’re still left with that legacy of poor health, and also just in terms of the economic cost for society as well. You have the patterns of poor health passing through the generations. A lot of the researchers in that field are now arguing that politicians should be taking account of the research, and that any sort of social policy is, in effect, a health policy. The level of inequality that you have is going to be feeding through into the health of those people.
UR: It’s kind of like when people try to artificially isolate environmental health from personal health. You can’t really separate the two.
JM: That’s true. You have so many different things that are entwined in terms of lifestyle and environment, and then people who are growing up in adversity will also have poor health because their lifestyles are not as healthy. There are a lot of different things to try and sort out, but when researchers do try to control for that, it does seem that it’s not all explained by lifestyle. There are sort of psychological effects as well. As you say, they’re affecting each other, so it’s kind of impossible to tease apart. Then, we have the animal research as well, where you can do the sort of direct experiments, looking at the effects of stress in early life, and there they are seeing the direct effects on physiology and gene expression.
UR: Speaking of society at large, you also touch on the importance of having a social network.
JM: The importance of social connections to protect us against the effects of stress. There’s a lot of work on social isolation and loneliness, showing that it’s as dangerous from an epidemiological point of view as smoking, obesity and a lack of exercise. Then there’s a lot of work on the mechanism suggesting that just having strong social relationships seems to protect us. Social isolation and rejection seems to act as a very potent stressor in itself, but having strong social relationships protects us from the physiological effects of other stresses when they come.
So, we don’t get as stressed by things if we have strong social relationships. I found that research pretty compelling. Interestingly, it’s not your sort of objective number of connections—the number of people you mix with isn’t the important thing. The important thing seems to be how lonely or connected you feel yourself to be. If you’re the sort of person who might have only a couple of close friends, but you’re completely happy with that and feel connected and satisfied with your social relationships, that’s fine. You don’t need to suddenly rush out and get loads more friends. Whereas, other people need to be surrounded by more people before they feel connected. It’s all about finding the level of social connection that is right for you and that you feel comfortable with.
UR: So it’s more about quality than quantity.
JM: Absolutely. And also the idea that you can be surrounded by people, sometimes, and still be feeling very alone. That kind of makes sense from an evolutionary point of view, because in the past—as John Cacioppo, who is one of the researchers in this field, sort of points out—being among a hostile tribe was just as dangerous as being alone. So, you can be living in a busy city, or at the sort of enemy end of a football stadium, or in a bad marriage—you can be surrounded by people living very close to you—and still feel alone.
UR: Which, when you think about it, makes sense.
JM: Loneliness has an important function. The researchers compare it to other biological drivers, like hunger and thirst. In the evolutionary past, being lonely and isolated was an imminent threat to our survival. Loneliness sort of developed as a drive to make us connect, because it is so important for us.
What I was interested to discover was that when people are chronically lonely, over long periods of time, that can actually start to affect the brain. It affects the brain in ways similar to chronic stress. It makes us hyper-vigilant to social rejection, which can make people act in a sort of counterproductive way. They become much more judgmental of the people around them, much more defensive — sort of judging people before those people even have the chance to reject them.
I think understanding that is helpful to try and work out how to help very lonely people become more connected. It’s not just a case of putting them in a room with a whole lot of other people. You have to try and sort out those fears and those attitudes, and try to help them understand why they’re acting the way that they do and to help them to start to trust people again.
UR: What do you hope is the main takeaway from the book for readers?
JM: Maybe we covered it a bit, but one of my main messages in the book really is that the influence of the mind on health is not mysterious or magical. It’s just biology. It’s just a matter of survival. We’ve evolved so that psychological cues influence our physiology. They help to prepare our body for challenges that we’re about to face, rather than the body always waiting for physical signals—injury or infection—we can use psychological cues to get one step ahead to prepare our physiology for that. That goes for everything from the amount of pain we feel to immune responses.
So, I do see it as a scientific thing. It’s something that we can study scientifically. I’ve probably already said this, but in radio interviews where I mention the influence of the mind over the body, suddenly people are asking me about psychic healing and past life regression therapy and energy crystals and things. It’s almost as though if the mind affects the body, that it has to be some sort of magical mysterious thing, and I don’t think that it is. It’s just biology.
Jo Marchant is the author of Decoding the Heavens, shortlisted for the Royal Society Prize. She has a PhD in genetics and medical microbiology and has written on everything from the future of genetic engineering to understanding archaeology for New Scientist, Nature, the Guardian and Smithsonian. She has appeared on BBC Radio, CNN and National Geographic. She lives in London. You can also find her online at www.jomarchant.com and on Twitter @JoMarchant ().
A version of this interview originally appeared in the Chicago Review of Books.