The Placebo Effect
Imagine a treatment that can relieve pain, improve sleep, reduce stress, ease nausea and reduce depression. In fact, it can help with almost any illness you can imagine. It’s free, available everywhere and has no nasty side-effects. It’s not new, nor is it high-tech.
That treatment is the placebo effect — the mind-body phenomenon that has been scorned for decades in medicine, but which contemporary science is proving to have powerful potential for healing.
The term “placebo effect”, also known as the “placebo response”, is used in medical literature to describe what happens when a “fake” treatment, such as a sugar pill or sham acupuncture, improves a patient’s condition.
It was first used in this context in 1955 by US physician Henry Beecher. In a now-famous article, Beecher collected data from 15 studies with 1082 patients suffering varying degrees of pain. He showed that a placebo painkiller was effective in an average of 35.2 per cent of cases. Since then, innumerable researchers have verified the importance of the placebo effect in treatment for a range of conditions.
Researchers use groups receiving a placebo treatment in their studies to help separate how much benefit comes from the so-called active treatment (such as a drug or type of therapy) from what can be attributed to the placebo response. Placebo effects generally occur in about 30 per cent of cases.
Shifting the stigma
Because placebos are used as “fake” treatments to judge how effective a “real” treatment is, the placebo effect has developed a negative stereotype in medical circles. “Historically, people who responded to placebos were thought to be gullible or thought to be making up their symptoms, or they didn’t have a real medical problem,” says Associate Professor Ben Colagiuri from the School of Psychology at the University of Sydney. Some doctors even used placebos to weed out patients with “genuine” problems from those who were faking symptoms, or whose symptoms were psychosomatic, he says.
Rather than work through one pathway, the placebo effect seems to operate through the various systems the brain already uses to effect healing in the body.
But, thanks to growing research in the area, attitudes are changing. “I think we’ve moved on from that view now,” Colagiuri says. “It’s becoming more widely accepted that placebos can have genuine beneficial effects in at least some patients for at least some conditions.”
Dr Kate Faasse from the School of Psychology at the University of New South Wales, agrees. She explains that research has failed to connect personality traits, such as gullibility, to the placebo effect. “People who respond to placebos are just normal people for whom that treatment context is particularly effective. It’s absolutely nothing to do with being any of those negative stereotypes,” she says.
Social & cultural factors
Rather than dismiss the placebo effect as a mystical happening that causes people to respond to sham treatments, or merely a tool in finding new drugs worth pursuing, some pioneering thinkers are working to discover just how the placebo effect works, with a view to harnessing its healing power.
One factor that has proven to enhance placebo effects is social context. At Stanford University, researchers gave study participants a pin-prick on an arm to cause an allergic skin reaction. Then a placebo antihistamine cream was applied by a doctor. In one group, the doctor had a spotless desk and a badge indicating seniority, and treated the subjects with warmth and confidence. In the other group, the same doctor had a cluttered desk and a student doctor badge, and was aloof and bumbling in interactions with the subjects. Results showed a significantly stronger response to the antihistamine cream in the group treated by the apparently warm and capable doctor.
Cultural context is another example. Colagiuri gives the example of someone who has been brought up with Western medicine compared to someone more used to traditional Chinese medicine (TCM). “You give them [both] a pill and say, ‘This is a powerful painkiller; it will help you get better”, but it’s actually a sugar pill. Or you give [them both] acupuncture but it’s actually sham acupuncture.
“You can pretty reasonably expect that you’ll get a much larger placebo effect in the Western medicine-exposed person who gets the pill, and a larger one in the TCM-exposed person who gets the acupuncture,” he says. “We can’t say that one is a placebo responder and one is not. We need to understand the whole treatment context including the individual’s prior experiences in order to predict whether they’ll have a placebo effect or not.”
In fact, we all have the capacity to trigger the mind-body healing mechanisms that are at the heart of the placebo effect. As Faasse says, “Most of us can heal from a cold or a cut. It’s those same processes that we’re activating, we think, with the placebo effect.”
Your inbuilt pharmacy
Science is still exploring exactly how the ability to tap into our healing capacity works, but one thing is certain: positive expectation plays a powerful role, as does prior experience, explains Faasse. “Those two go hand in hand. If you have positive previous experience you also tend to have [a] positive expectation.”
These positive expectancies apparently trigger the body’s inbuilt pharmacy in a way that’s “much more complicated than we initially thought”, says Faasse. “It seems like just thinking about something can activate the neural networks in your brain associated with that outcome and perhaps that’s what’s triggering these endogenous (built-in) mechanisms.”
This shouldn’t be surprising, given that your brain is the dispensary for the inbuilt pharmacy available to your body. Every day, you manufacture multitudes of medications that regulate your body functions and keep you healthy: painkillers, antibiotics, antidepressants, anti-inflammatories, immune stimulants, cancer-fighting drugs, blood pressure stabilisers, stimulants and many more.
Therefore, rather than working through one pathway, the placebo effect seems to operate through the various systems the brain already uses to effect healing in the body. In pain, for example, it encourages the body to produce more endogenous opioids (painkillers). In Parkinson’s disease, it can cause the brain to produce more dopamine, the neurotransmitter that is deficient in this condition.
Placebo in practice
The placebo effect has been most widely studied in the treatment of pain and proves just how powerful the influence of the mind is on the body. Faasse describes a study conducted by Italian researchers on the placebo effect in post-surgical pain. One group of patients had doctors tell them they were receiving painkillers and give them the drug. The other group got the same dose of the same drug, but delivered by a machine, so they didn’t know when it was being given. The medication lost one-third to one-half of its effectiveness in the second group.
In his lab, Colagiuri has tested the placebo effect by giving electrical shocks to healthy volunteers. His team found that giving participants a placebo pill, while telling them it was a powerful painkiller, tended to reduce their response to the painful shock.
He has also researched sleep in a group of people with clinically significant insomnia. “By the end of the placebo treatment, that group was below the cut-off for clinically significant insomnia. We’re not talking about just a statistically significant difference, but one that’s actually changing where, on average, this group is landing on the insomnia scale,” he says.
At the end of the trials, research protocol means participants are told they were receiving placebos. “The effects are so strong in some individuals that when you say, ‘We were actually giving you placebos’, they say, ‘No, you weren’t. I got better so you must have been giving me a real drug.’”
In new research that puts a fascinating twist on the placebo effect, it appears that even people who know they are receiving a placebo can benefit. This type of research has been dubbed “open label” placebo research. Faasse explains that giving people an open-label placebo, while explaining “how powerful the placebo effect is and how it triggers all these different psychophysiological mechanisms that can improve health”, still works.
“We’ve seen it across a range of health conditions: irritable bowel syndrome, chronic pain, allergic rhinitis, depression.” In her lab, Faasse has given open label placebos to healthy participants, telling them that because of what we know about the mind-body connection, it can improve their wellbeing.
At the end of the study, participants were asked about their experience. One of them said, “I’d been really struggling … This week I had more energy. I felt like this great weight had lifted off me. I couldn’t tell you for sure that it was the placebo, but damn it was a good week!”
Faasse believes that evidence for the placebo effect has probably reached a level where it can be considered a therapy in its own right. “It’s this interesting blurry line of — can we call placebo an evidence-based therapy? I think we have enough data now to say as long as it’s ethically delivered … that we really do have quite substantial evidence that it can be beneficial.”
Faasse notes that the placebo effect forms a vital component of just about every medical treatment, whether it’s conventional medicine or alternative therapy. She believes alternative health practitioners are particularly skilled at harnessing placebo effects. Compared to the time-pressured nature of Western medicine, alternative therapists often have longer consultations, more warmth and empathy and better communication of the expected benefits, all of which can tap into placebo effects, she says.
Tapping into its healing
When it comes to harnessing the healing power of the placebo effect, studies have shown that simply visiting a healthcare practitioner can do it. “Having interactions with a clinician and getting care can actually facilitate this mind-body healing process that your body’s totally geared up to do, anyway,” says Faasse.
Warmth and empathy in the clinical encounter can further enhance placebo outcomes. One study gave placebo acupuncture to patients with irritable bowel syndrome. The patients in the group who were intentionally treated with warmth and attention had significantly better outcomes than those who weren’t.
Faasse explains this may be because a warm and empathic clinician is better able to communicate the positive expectations that are known to drive placebo responses. One fascinating area of research is how communication affects treatment outcomes. The way information is conveyed can make a big difference to how it is perceived by patients. For example, if a doctor tells you there’s a 24 per cent chance you will suffer a headache as a side-effect of medication, that can sound quite different from being told there’s a 76 per cent chance you won’t.
“It’s logically identical information but emotionally quite different,” says Faasse. Her team is looking at ways to help practitioners frame information so it’s more helpful to patients. If you are able to find a clinician who demonstrates warmth and empathy, in addition to competence, you have a better chance of harnessing the healing power of the placebo effect.
For health professionals, Colagiuri advises thoughtfulness in their communication with patients. “They obviously have an ethical and moral obligation to patients to be honest about what they’re administering, the possibility of improvement and the possibility of side-effects. But the way in which they communicate that information could be having quite a profound effect,” he says. “Try to take into consideration what the patients’ expectancies are and how they want to be informed about different components of the treatment.”
For patients, he adds that spending hours checking Google for possible side-effects is not very helpful. Trying to maintain a positive expectation about the usefulness of a treatment, and not dwelling on potential negative effects, is a better approach. He also suggests patients should talk to their practitioners about how likely any potential negative effects really are, because “often the risk can be lower than what seems to be presented online”.
Power of choice
Another thing that has been proven to enhance the placebo effect is having a choice. Faasse and her team have done research looking at how the way medicines are presented can influence placebo effects. They found that patients responded better when they had a choice about which pill they took, even though they were the same medicine at the same dosage.
This has important implications for clinical practice, where there are often several ways to treat a condition. Having a discussion with your practitioner about available treatment options, and being given the opportunity to make even small choices, can harness placebo outcomes.
While these factors are recognised as enhancing placebo outcomes, we don’t yet know the extent to which people can harness it themselves. Research is still to show whether having a positive attitude itself or just trying to expect the best works or not, Colagiuri says. “That’s still being found out. I’d be a little bit reluctant to recommend that too strongly because it also suggests that you’ll only get better if you believe those things. It puts too much emphasis on the patient.”
Nor does he advise choosing a treatment simply because you have a positive expectation about it. There’s a plethora of misinformation around, some of it engineered to target people who are sick and vulnerable. This puts people at risk of choosing treatments that are often expensive, have no supporting evidence for their effectiveness and may even be harmful. “You don’t want to give up a proven treatment just because you think another one’s more effective,” he says.
The placebo effect does have limits. Just because you have a positive expectation about a therapy doesn’t guarantee it will work. People have died still believing their treatment is going to cure them. Nonetheless, harnessing the placebo effect is a promising way to tap into mind-body medicine. Faasse sums it up well, saying, “We’re all born to be placebo responders. All we’re doing is enhancing our own natural healing capacity.”
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