Cure: A Journey into the Science of Mind Over Body

by Jo Marchant

  Whorwell has just published an audit of another thousand patients treated with gut-focused hypnotherapy.27 He reels off the stats: 76% with a clinically significant reduction in symptoms; 83% of responders still well after one to five years; 59% taking no medication, 41% taking less; 79% consulting their doctor less often or not at all. He is due to retire soon, though, and is planning no more trials. “I think we’ve probably blown it by then,” he says.

  “We have produced a lot of good research, incontrovertible research. Yet we’re always fighting the people who fund treatment. They’re always saying there’s not enough evidence. How much more evidence do they want?”

  Perhaps he’s right, and the barriers to acceptance for the therapy, with its checkered history, are just too strong. But across the Atlantic, hypnosis is being reinvented yet again.

  I’m floating slowly through a shimmering ice canyon. The walls are sheer and there’s a ribbon of blue water below. Perched on icy shelves on either side of me are penguins, waving their flippers, and snowmen with smiles made of coal. I throw snowballs at them, and if I get a direct hit they explode in a flurry of triangular shards, leaving their smiling faces in the air like a row of frozen Cheshire cats. In the background, Paul Simon is singing, “You can call me Al.”

  I look up towards snowflakes and a dark sky; down to the water; then spin around. But mostly I let myself drift forwards. There are ice bridges to watch for, some supporting glossy igloos. The snowmen start throwing snowballs back at me, so after a while I stop trying to hit the men and aim for their missiles instead, setting up satisfying mid-air collisions.

  As I fly around a bend I see a family of woolly mammoths with huge curved tusks, standing knee-deep in the water below. I fire a snowball at one and he trumpets. Then some flying fish appear, silver blue, leaving trails of snowflakes as they leap downstream.

  At various moments as I progress down the canyon, I become vaguely aware that something is happening to my foot. There’s tingling, then something that if I thought about it might be burning pain. But that’s in another world, of no relevance to this magical canyon, and I can’t be bothered to focus on it right now. I’m more interested in whether I can get those mammoths to explode.

  —

  IN 2008, Lieutenant Sam Brown was deployed for his first tour of duty, to Kandahar in Afghanistan. At dusk on the last day of his mission, a call came through from a nearby platoon to say that they had been ambushed. Brown led his men through the desert to help, but on the way his Humvee hit a roadside bomb.1

  He saw a bright flash as the armored vehicle lifted into the air; seconds later, it was a twisted pile of wreckage. He doesn’t remember how he got out, but his body was on fire. He thought he was going to burn to death by the blast crater, but with the help of his gunner, he smothered the flames with handfuls of sand. By the time they had put out the fire, the sleeves of his uniform had burned off and the skin was gone from his body, face and hands. The flesh left behind was raw red or charred black.

  Brown was eventually airlifted to Brooke Army Medical Center in San Antonio, Texas. He had suffered third-degree burns over much of his body. Also referred to as full-thickness burns, third-degree burns destroy all layers of the skin. Doctors kept him sedated for weeks while they harvested skin from his back and shoulders to cover the worst. He woke to a series of further surgeries, including the amputation of his left index finger. But the hardest thing was enduring the daily sessions when nurses scrubbed dead tissue from his raw wounds. It was like being burned all over again.

  Later, as his burns started to heal, he needed daily physiotherapy, which turned out to be even more painful. Over wounds as extensive as Brown’s, scar tissue tends to thicken and contract. To ensure that he would still be able to move freely once his burns had healed, his therapists had to force his body and limbs past their limits, to stretch and tear the scar tissue as it formed.

  In the U.S. each year, an estimated 700,000 people visit emergency rooms for the treatment of burns, of whom 45,000 or so are admitted to hospitals.2 To help them through their grueling wound-care and physiotherapy sessions, they are given opiate drugs at some of the highest doses used in medicine. But the amount that doctors can give is limited by their side effects—from itching and being unable to pee to loss of consciousness and death. At the highest safe doses, many patients are still left in agonizing pain. And taking opiates for months puts them at risk of addiction.

  Brown tried desperately to limit the drug doses he was taking. He found the physiotherapy so unbearable that at times, his superior officers had to order him to undergo treatment. But he feared becoming an addict even more. Then he was asked if he wanted to take part in a pioneering research trial.

  —

  THERE’S NO shortage of painkilling drugs in health care. We have over-the-counter tablets such as aspirin and ibuprofen; potent narcotics such as morphine and codeine; sedatives such as ketamine. Antidepressants, anticonvulsants and corticosteroids can all be used for relieving pain. Doctors can anesthetize a small spot of skin, an entire region of the body, or render a patient completely unconscious. Unfortunately, none of this means we have eliminated pain in medicine. Not even close.

  Pain is a particular problem for people undergoing medical interventions and procedures during which they have to be awake—wound care for burn patients like Brown, for example, or keyhole surgery, which is increasingly replacing open surgery for everything from biopsies and diagnostic tests to inserting medical devices and destroying tumors. As Brown’s case shows, pain medications on their own often don’t do enough, leaving even drugged-up patients in agony.

  Then there are the millions of people affected by chronic pain, in conditions from arthritis to fibromyalgia. Over the last couple of decades there has been a surge in the amount of opioid drugs such as OxyContin—artificial equivalents of the endorphins involved in the placebo effect—prescribed for such conditions. These used to be drugs of last resort, used only in severe cases such as terminal cancer. But they are now routinely prescribed in patients with mild to moderate pain, who can end up taking them for months or years.

  The trouble is, unlike natural endorphins in the brain, these artificial versions swamp the brain’s opioid receptors. In response, the receptors become less sensitive to the drug. We develop tolerance, needing higher and higher doses for the same effect. It also means the drugs are terribly addictive. Coming off them leaves people with horrible withdrawal symptoms including anxiety and hypersensitivity to pain, because their desensitized receptors no longer respond to natural endorphins as they should.

  The increase in prescriptions has led to a surge in opioid-related addictions and fatal overdoses that has been described as “one of the great unfolding tragedies of our time.”3 This is a particular problem in the U.S., which makes up less than 5% of the global population but consumes 80% of the world’s supply of opioid prescription drugs.4 By 2012, 15,000 Americans were dying each year from prescription pill overdoses, more than from heroin and cocaine combined.5 In 2013, the U.S. Centers for Disease Control and Prevention (CDC) named painkiller addictions the worst drug epidemic in U.S. history.6

  Which begs the question, are we approaching pain all wrong? Instead of prescribing higher and higher levels of addictive painkillers, some researchers claim there is another way. They are harnessing the power of illusion to reduce drug use and ease our pain.

  —

  WHEN I arrive at the experimental pain lab at the University of Washington Medical Center in Seattle, I’m greeted by research assistant Christine Hoffer. She asks me to remove my right shoe and sock, then straps a small black box tight against the skin of my foot. It’s designed to inflict pain, she explains, by rapidly heating up. Usually Hoffer gives her volunteers repeated electric shocks too—but luckily for me that equipment isn’t working today.

  She activates the box for 30 seconds, and asks me to score how painful it is on a scale of one to ten. Then she increases the heat in half-degree inc
rements, looking for a response roughly in the middle of the scale. Eventually I score 6 out of 10 for both intensity of pain and unpleasantness. It’s a stinging, burning sensation, not enough to leave a blister but intense and impossible to ignore. This is the temperature that Hoffer will use for the experiment.

  She fits me with virtual reality goggles that project high-resolution 3D images, and noise-cancelling headphones with surround sound. Suddenly I’m floating in the snow, admiring the sparkling walls of a canyon made of ice. Hoffer shows me how to move around and fire snowballs with a computer mouse. The graphics are cute but not super-realistic, particularly by the standard of many of today’s video games. Yet there’s an immersive quality that I’ve never experienced before. All sights and sounds from the outside world are blocked out, and as I look around, the virtual world extends above, below and behind me. Cartoonish as the landscape is, I feel that I’m inside it.

  I spend ten minutes with the snowmen and penguins, during which Hoffer turns on the heat box three times. Afterwards she asks me to score the experience again. My pain intensity score comes down a bit, from 6 to 5 (but each time felt as a brief peak rather than the longer plateau I endured before). Meanwhile the unpleasantness of the pain falls dramatically from 6 to 2. I score my overall enjoyment of the experience as 8 out of 10, pretty fun, and would have been happy for another go.

  It’s all about attention, says anesthesiologist Sam Sharar, who runs this lab. The brain has a fixed capacity for conscious attention. We can’t increase or decrease it, he tells me, but we can choose what we pay attention to. If we focus on a painful sensation, it will increase our experience of that pain. But if we think about something else—something safe, pleasant, far away—the pain we feel is dimmed.

  Visual imagery is a particularly potent form of distraction. Sharar shows me a video of the hiker Aron Ralston—who was forced to amputate his own forearm with a pocketknife after five days trapped in a remote Utah canyon in 2003—describing afterwards how mental images helped him to survive his ordeal.7

  On his fifth night in the canyon, Ralston was shivering with cold, badly dehydrated and in agonizing pain from his hand, which was crushed beneath a fallen boulder. He knew that he was going to die. Then he saw a vision that blocked out his traumatic surroundings. “There was a little boy about three years old,” recounts Ralston. “He was wearing a red shirt, and he was playing with a truck, moving it around, making little brrm brrm noises.

  “Then he stopped, and he looked over his shoulder, and he came running over to me, and I could see myself pick up this little boy and then boost him up there on my shoulder, where we were looking straight into each other’s eyes. And I knew that I was seeing the face of my future son. Then that vision blacked out and I was back in the canyon, shuddering from that hypothermia.”

  Ralston goes on to say that imagining his loved ones helped him to tolerate the pain of cutting off his arm. “As I cut it, I felt the worst pain that I have ever experienced in my life. For 30 seconds, all I could do was close my eyes and breathe. But I never said ow, I never shed a tear, I never cried. And that’s not because I’m superhuman. It’s because when I opened my eyes, all I could think about, all I could imagine, was seeing my family again.”

  For Ralston, an internally generated world—images of his family and imagined future son—helped to focus his attention away from the pain of his horrific ordeal. The virtual ice canyon I’ve just experienced, says Sharar, is an attempt to create artificially that same effect.

  It’s the brainchild of Hunter Hoffman, a cognitive psychologist at the University of Washington who specializes in building virtual worlds. Back in the 1980s, Hoffman had just created “kitchen world,” a virtual kitchen fitted with countertops and cabinets as well as objects you could pick up, like a teapot, toaster, frying pan—and a wiggly-legged spider in the sink. Hoffman hoped to help people with arachnophobia, by giving them a safe place to get used to contact with spiders.

  Then he heard from a friend about the work of David Patterson, a psychologist who was using hypnosis to ease the pain of burn patients at UW Harborview Medical Center, also in Seattle. The friend thought that the technique might have something to do with distraction. I’ve got a distraction for him, said Hoffman, and the pair started working together, to see if virtual reality (VR) could help patients going through some of the most painful procedures in medicine. First they put them inside kitchen world. “It worked with the very first kid,” says Hoffman. So he set about designing a virtual world just for burn patients.8

  At the time, making any kind of virtual world was at the cutting edge of technology. Hoffman used a supercomputer made by the company Silicon Graphics, which cost $90,000 including a heavy helmet, and based his new landscape on military flight simulator software that modeled a fighter jet taking off from an aircraft carrier. It needed a few adjustments. “We were super worried about simulator sickness,” he tells me. “A lot of burn patients are nauseous from their pain meds. I was convinced from the very first patient that VR had the potential for pain distraction, but I was worried that nausea would be a showstopper.” So he closed in the terrain to a narrow canyon to discourage people from changing direction or spinning in circles. And he built it out of soothing ice. He called it Snow World.

  Twenty years later, the essence of Snow World is still the same. But the supercomputer and helmet have been replaced by a laptop and hi-res goggles (helmets are no good for people with burns on their heads and faces). Hoffman has designed electricity-free fiber-optic goggles, which carry signals down 1.6 million tiny glass fibers per eye, so they can be used in water tanks while patients have their burns scrubbed. He has also upgraded the graphics, and changed the background music. Paul Simon once tried Snow World at an exhibition, Hoffman explains. He loved it but hated the ethereal, spacey music they were using, so he donated his own.

  The UW team has also carried out a series of randomized controlled trials on healthy volunteers (with Hoffer’s heat box and electric shocks) and on burn patients at Harborview. They’ve found that Snow World works strikingly better than other forms of distraction such as music alone, or video games. The essential ingredient seems to be how immersed you feel in the world. The greater the sense of presence, the more pain relief people feel.

  In the lab, Snow World consistently cuts pain scores by 35%, says Hoffman, compared to around 5% for music. And when used in combination with pain medication, it reduces patients’ pain ratings by an extra 15–40% on top of what they get with drugs.9 The researchers see the effects not just in subjective pain scores but in brain scans too, with activity in pain-related brain areas almost completely extinguished.10

  The team is still experimenting with ways to boost the effect—small doses of the hallucinogenic drug ketamine seem to improve the sense of immersion people feel, for example. But the Snow World technology is already being used in around 15 hospitals across the U.S. One of them is the Brooke Army Medical Center (BAMC), in Fort Sam Houston, Texas, which has treated hundreds of soldiers burned in combat in Iraq and Afghanistan. Most of them suffered burns from improvised explosive devices (IEDs)—roadside bombs, car bombs, suicide bombs, or as Hoffman puts it: “These real fancy bombs that would really blow up a Humvee super-bad.”

  Hoffman and his colleagues carried out a trial of 12 soldiers at BAMC, including Lieutenant Brown.11 When they were immersed in Snow World during their physiotherapy sessions, their worst pain score dropped nearly two points compared to the part of the session spent without it. The proportion of time they spent thinking about the pain dropped from 76% to 22%. And whereas they rated their normal physiotherapy as “no fun at all,” they rated therapy while in Snow World as “pretty fun.”

  Snow World worked best for the six patients who started off with the worst pain; the soldiers who needed it most. For example Brown’s worst pain score dropped from 10 to 6, and when in Snow World he rated his therapy—previously so grueling—as actually quite fun. He later told a reporter for
GQ magazine that it reminded him of skiing with his brother during Christmas break in Colorado, back when he was still a cadet at the U.S. military academy at West Point.

  After the session he gave Hoffman his verdict: “I think you guys are on to something.”12

  —

  ONE NIGHT in April 2014, 22-year-old Terrell was driving at 80 mph down a high street between Kent and Des Moines, just south of Seattle, when he lost control of the car. The vehicle flipped, did two turns in the air and skidded to a halt. Then it caught fire.

  An ambulance brought Terrell to Harborview Medical Center with a broken arm and serious burns to his leg and chest. “When I woke up, I was in the worst pain,” he tells me. “There were tubes in my throat, tubes everywhere. I was trying to get them out, they were stopping me. My face was swollen.” There were burn marks all over his body. Once Terrell had calmed down he called his girlfriend to tell her he had been in an accident. “She didn’t believe me,” he says. “But when she got here, then she knew.”

  A month after the crash, Terrell is lying in his hospital bed, dressed in a green robe with gathered frills at the shoulders and propped up on about five pale blue pillows. He is slightly built, with a tuft of a beard on his chin and unshaven sideburns. Two coin-sized scars gleam white against his dark skin, next to his right eye and on his forehead. His left leg is heavily bandaged, with yellowy-brown serum seeping through at the foot.

  He’s surrounded by the remains of unfinished meals—milk cartons, a nibbled muffin, a dinner plate, yogurt containers and empty cups—and a bunch of helium balloons with shiny foil messages: “You’re so special” and “Get well.” A few feet away on the other side of a curtain is a huge, angry-looking man; his scowling face is burned pink and brown and his bandaged arms stick straight out to either side. He seems to have enemies outside the hospital; his name has been removed from his hospital records for his own protection, one of the medical assistants whispers to me as we pass.