Beyond Belief

Not long ago, David Rosmarin found himself in an awkward situation. Rosmarin, an Orthodox Jew, wears a yarmulke, and this outward statement of faith rendered him a kind of magnet for McLean Hospital’s more spiritually inquisitive residents. Yet, as a new instructor in psychology in the hospital’s Department of Psychiatry, he didn’t want to overstep his boundaries when patients—not his own—tried to engage him in conversations regarding spiritual issues. So for his first six months at the hospital, he offered only a brief palliative: “I’m sorry, but you’ll need to speak with your case manager. I’m not on your team.”

Rather than continue to skirt the matter, Rosmarin and a few colleagues developed a spirituality and cognitive behavior therapy group at one of McLean’s day programs. Patients raved about it, many claiming on their exit interviews that it was the best part of their outpatient treatment.

The success of the group led Rosmarin to think critically about his years of psychiatric training. He realized that the concept of querying a patient about his or her religious beliefs fell into an educational blind spot.

Article of Faith

The field of psychology, Rosmarin’s chosen field, is a rather secular enterprise. A 2007 study in Professional Psychology: Research and Practicefound that psychologists are five times more likely to be atheists than non-psychologists. For that reason alone it’s hardly surprising that the number of studies examining the relationship between spirituality and mental health is, to say the least, scant.

“I realized it was time to start getting some science behind this,” Rosmarin says.

One concept he had been pondering was whether a person’s religious beliefs might affect treatment outcomes. He decided to find out. With funding from the Gertrude B. Nielsen Charitable Trust, he recruited 159 patients and assessed their belief in God using a five-point scale that ranged from no belief at all to strong faith in God. He also evaluated the patients’ psychological status over a brief course of treatment, measuring such variables as depression, well-being, and intent to self-harm.

The findings surprised Rosmarin. Not only was a belief in God strongly correlated with positive treatment outcomes—the stronger the belief, the better the recovery—but the intensity of the belief in God also paralleled the degree of hope placed in therapeutic interventions. Stated another way, the findings, reported in the October 2012 online issue of the Journal of Affective Disorders, showed that nearly all the atheists in the study felt their treatments would fail.

Pressure Points

Although the connection between patients’ personal beliefs and their physical health remains peripheral to most medical training, many notable figures in the School’s history have taken the subject seriously. Oliver Wendell Holmes, Class of 1836 and HMS dean from 1847 to 1853, emphasized how compassion within the doctor–patient relationship expedited healing. William James, Class of 1869 and author of The Varieties of Religious Experience, supported the “mind-cure movement,” which allowed for thinking yourself to better health, and famously argued that emotions are the result of physiological conditions. And Walter Bradford Cannon, Class of 1900 and the researcher who characterized the “fight-or-flight” response, studied the relationship between emotions and the nervous system.

Cannon, in particular, is close to the heart of Herbert Benson ’61, an HMS professor of medicine and the founder of what is now the Benson–Henry Institute for Mind Body Medicine at Massachusetts General Hospital. It was in the same laboratory space at HMS where Cannon conducted his research nearly a century ago that Benson identified fight or flight’s antipode: the relaxation response.

During the 1960s, Benson was toying with a theory that grated on the sensibilities of his fellow cardiologists, namely, that emotional states could affect blood pressure. At the time, high blood-pressure levels were widely considered to be the exclusive byproduct of kidney disease.

“The very idea that there could be a mental component to high blood pressure was heretical,” Benson recalls.

To test his theory, Benson and his colleagues taught primates to regulate their blood pressure in response to environmental stimuli. The findings, published in 1969 in the American Journal of Physiology, caused a blizzard of media attention. Students who practiced transcendental meditation claimed that they could achieve the same result, and they wanted Benson to demonstrate their claim. After much reluctance and deliberation, he agreed.

Benson enrolled volunteers who practiced transcendental meditation and monitored their brain activity, breathing, blood pressure, and metabolism during meditation. He found that the meditative state decreased metabolism, blood pressure, and breathing rates, and altered brain waves.

“This was the diametrical opposite of the fight-or-flight response,” he says. It was the phenomenon he ultimately called the relaxation response.

Om Schooling

Benson has spent the past four decades of his career studying, and promoting, the health effects of different meditative techniques that elicit this response. Such techniques, he says, can successfully treat a variety of health conditions, particularly those exacerbated by stress, which account for the lion’s share of doctor visits. In fact, a 2008 study in PLoS ONE, reported by Benson, Towia Libermann, an HMS associate professor of medicine and director of the Genomics Center at Beth Israel Deaconess Medical Center, and colleagues found that the relaxation response can positively affect the expression of genes related to immunology, inflammation, and aging. This was, according to the researchers, the first comprehensive study to show a connection between meditation and gene expression.

Despite the veneer of Eastern spirituality often associated with meditation, there is nothing especially religious about Benson’s approach. Patients are taught to sit comfortably, ease their muscles, and draw attention to their breathing by synching it to a word or short phrase that they repeat throughout the session. Sometimes they’re encouraged to visualize a soothing image or memory. In one sense, this looks like something you might learn in anger management 101.

Patients who identify with a particular religion, however, are offered the choice of using a word or short phrase that is spiritually significant to their beliefs: Catholics might say, “Hail Mary, full of grace,” Jews could recite, “Sh’ma Yisrael,” and Muslims might repeat, “Insha’Allah.”

“By having people repeat something they believe in, we help ensure compliance with the relaxation response while also building in the placebo effect,” he says. “Belief is essential.”

Sweet Nothings

“Placebo” is a loaded term, one that implies deception or the power of positive thinking. Latin for “I shall please,” it implies false flattery. In clinical trials a placebo sets the bar for determining a “real” drug’s efficacy. If a drug fails to perform better than a placebo, it’s deemed useless, no more effective than the boost gained from a good attitude.

Ted Kaptchuk, an HMS associate professor of medicine at Beth Israel Deaconess Medical Center, has long been carefully studying the placebo effect. As a result, he has developed surprisingly nuanced views on what is meant by the mind–body connection.

“Personal beliefs, whether they’re religious or not, give solace during sickness. But does that translate into improved clinical outcomes, improved symptomatology? I think the evidence is just not there,” he says. For someone like Kaptchuk, a researcher who time and again has demonstrated the powerful effects placebos can have on those who take them, such a statement might seem incongruous.

But for Kaptchuk, equating placebo with belief is far too simplistic. A small 2010 study of his showed that placebos work even when patients are told that the pill they are taking contains no active compound. In the common understanding of the placebo effect, such results simply don’t make sense.

“We don’t understand the placebo effect because we are wedded to our current cognitive frameworks,” he says. “I feel there are latent variables that we don’t measure. Like the way a physician looks a patient in the eyes, the way he leans forward, the tone of his voice, the sights and smells of the examination room.” In other words, the exam’s ritual. Supporting this view, Kaptchuk’s team recently published in Proceedings of the National Academy of Sciences a study demonstrating that the environmental cues of positive placebo benefit can be activated nonconsciously, totally outside the awareness of the patient.

In 2011, Kaptchuk published a review article in Philosophical Transactions Btitled “Placebo studies and ritual theory: A comparative analysis of Navajo, acupuncture and biomedical healing.” In it he argues that the placebo effect is the culmination of the healing ritual—the offer, acceptance, and ingestion of a pill, even an inactive one. Participation in the medical and healing process probably influences the activity of neurotransmitters such as dopamine and serotonin.

This line of thought might help explain the perplexing results of a 2006 study in which Benson and colleagues observed the effects that intercessory prayers said by strangers had on cardiac bypass patients. The patients were divided into three groups: one whose members were not prayed for but did not know it; one whose members were prayed for but did not know it; and one whose members knew they were being prayed for. Participants in the first and second groups fared no differently during the recovery process. But the third group, those who knew they were being prayed for, had a higher incidence of complications.

Although the researchers noted that there are many variables that may account for this perplexing finding, it may be worth noting that the third group of patients received prayers minus the ritual—they had knowledge of intercessory prayer, but none of its context.

A Still Small Voice

William James saw religious experience as the closest thing we have to a microscope into the mind, and Rosmarin is clearly continuing this line of thought. The findings from his Journal of Affective Disorders study have inspired him to delve more deeply into the relationship between religious belief and mental health. He’s now investigating the effect of belief among geriatric patients and patients with bipolar disorder. Rosmarin is also looking into the potentially negative consequences that certain spiritual beliefs can have for patients with psychoses.

“There are so many questions we need to answer concerning belief and psychiatry,” Rosmarin says. “Basic questions, basic information that we just don’t have.”