Dashed Hopes–“The Pit of Despair”
Repeatedly being offered ineffective treatments will induce depression.
Posted Jan 25, 2020
Modern medicine is evolving in a dangerous direction with regard to patient care. The major, and often the only, factor in deciding to offer you a procedure or treatment is whether it’s covered by insurance and how well it is reimbursed. The effectiveness of the intervention is a lesser consideration.
Additionally, there is little accountability of the medical system for the outcomes unless there is severe negligence. One problem that is not often acknowledged is that of inducing depression from repeatedly dashing people’s hopes, especially patients with chronic pain, as there is already little or no promise of a cure.
This was powerfully demonstrated by Harry Harlow. (1)
“The Pit of Despair”
Harry Harlow was an internationally renowned psychologist who pioneered research in human maternal-infant bonding using primates. During the first half of the 20th century, it was felt that mothers should touch their children as little as possible. The leading mental health professionals aggressively discouraged mother-child interaction in research papers, lectures, books, and the media.
Interestingly or tragically enough, their recommendations were based on rodent research. Dr. Harlow was the leading force in changing the tide of opinion using various species of monkeys. His story is well-presented in an entertaining and informative book, Love at Goon Park by Deborah Blum. (1)
In the 1960s, he turned his attention, also based on primate research, to some of the smaller details of human interaction. One model he worked on for quite a while was that of inducing depression.
He used various isolation methods and ways of simulating parental neglect or even abuse. He consistently produced monkeys that were seriously disturbed, but he wasn’t able to cause depression. At the time, he was experiencing his own severe depression associated with his wife’s diagnosis of terminal cancer.
He finally found a consistent methodology to create depression by devising an apparatus that resembled an upside-down pyramid. The sides were steep but still allowed the monkey to climb to the top to peek outside. The top was covered with mesh.
Initially, the monkeys would repeatedly climb up to look out and quickly slide back down. Within a couple of days, they would give up, sit in the middle of the device, and not move. They became almost unresponsive.
What was even more disturbing was that when they returned to their families, they wouldn’t revert back to normal social behavior. It didn’t matter what problems the monkey had prior to the experiment. The abnormal monkeys became worse, and normal monkeys suffered the same fate. Even the “best” monkeys from stimulating and interactive families would succumb.
The researchers called the apparatus, “The Pit of Despair.” It was felt by the research team that this “learned helplessness” was from a combination of feeling the loss of a good life reinforced by occasional glimpses of the outside world and feeling trapped. Within half a week, every monkey spiraled down.
Profits over quality
The business of medicine, like any other business, is focused on making a profit. There are computer programs that monitor physicians' contribution to the profit margin. The most revenue comes from performing procedures, most of which have been documented to be ineffective for treating chronic pain. (2) The downsides include unnecessary costs, significant risks, and patients are often worse off than before the intervention. (3)
It has also been documented that only about 10 percent of spine surgeons are addressing the known risk factors for poor surgical outcomes. (4) Dr. Ian Harris, who is an orthopedic spine surgeon from Australia, has done extensive research on the utilization of ineffective procedures. He wrote a book, Surgery: The Ultimate Placebo (5), where he extensively documents the data behind many procedures that have been proven to be of no benefit, and it hasn’t stopped physicians from using them—at all.
Effective treatments are often not covered because they don't generate enough revenue. For example, expressive writing is a simple intervention that has been shown to help alleviate symptoms in multiple medical conditions. Its effectiveness has been well-documented in over 1,000 research papers. (6)
The most basic form of it is simply writing down your thoughts and immediately destroying them. It has been shown to decrease symptoms of asthma, depression, and rheumatoid arthritis, and improve students' athletic and academic performance. I had dinner with the original author of the technique, James Pennebaker, who is a psychologist from Austin, TX.
There is a lot of debate on why it works and what might be the best technique. But there is no questioning whether it works. It costs nothing, has minimal risk, but is rarely presented as a treatment option. Most physicians have never even heard of it. Why?
Mindfulness-based stress reduction has also been demonstrated to decrease pain in many papers and is usually not covered by insurance. (7) Several excellent pain programs in the Puget Sound shut down because they could not afford to keep them open.
Listening is a proven healing modality in addition to being a basic requirement to understand a given patient’s whole situation. (8) Dr. Francis Peabody, a famous Boston physician, was concerned about the intrusion of technology into the patient-physician relationship in 1927. One of his more notable quotes was, “The secret of care is caring for the patient.” (9)
The business of medicine
Currently, mainstream medicine is pretending to deliver medical care, while at the same time, people still trust their physicians. My observation is that it isn’t the individual physicians that are the core of the problem. The corporatization of medicine is backing everyone into a tight corner. Not only are we not given the time to talk to our patients, but many are often penalized heavily for not being “productive enough.”
The data continues to pile up regarding the ineffectiveness of modern medicine's approach to chronic pain. A recent comprehensive review article compared the papers looking at sham procedures versus interventions for chronic knee and back pain. Here is the conclusion.
A moderate amount of evidence does not support the use of invasive procedures as compared with sham procedures for patients with chronic back or knee pain. Given their high cost and safety concerns, more rigorous studies are required before invasive procedures are routinely used for patients with chronic pain. (10)
The data is particularly dark regarding surgery for back pain. There is not one paper in the last 60 years which documents that it is a viable solution.
You, the patient, don't feel heard. You are offered many random treatments, including physical therapy, chiropractic adjustments, injections, acupuncture, vocational retraining, medications, traction, inversion tables, spinal cord stimulators, and often surgery. No one has explained the nature of chronic pain to you. How many times can your expectations be dashed before you lose hope?
The additional tragedy is that chronic pain is a solvable problem, given the correct evidence-based approach. We don't need to keep searching for a cure when it already exists. Effective treatments must be covered, and the only group that can demand the necessary changes are patients.
1. Blum, Deborah. Love at Goon Park. Perseus Publishing, New York, NY, 2002.
2. Jonas, JB, et al. Are invasive procedure effective for chronic pain? A systematic review. Pain Medicine (2019); 20: 1281-1293.
3. Perkins, FM, and Henrik Kehlet. Chronic pain as an outcome of surgery. Anesthesiology (2000); 93: 1123-1133.
4. Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.
5. Harris, Ian. Surgery, The Ultimate Placebo. New South Publishing, Sydney, Australia, 2016.
6. Pennebaker, J and Joshua Smyth. Opening Up by Writing it Down.
7. Corder, G, et al. An amygdalar neural ensemble that encodes the unpleasantness of pain. Science (2019); 363: 2760281.
8. Davis, JE. Just listen: You will be truly amazed at all that you can hear. http://dx.doi.org/10.1016/j.annemergmed.2016.04.054
9. Peabody, FW. The Care of the Patient. NEJM (1927); 88:877-882.
10. Jonas, WB, et al. Are Invasive Procedures Effective for Chronic Pain? A Systematic Review. Pain Medicine (2019); 20: 1281–1293