Earlier this year, an interesting review was published in the open access journal Psychology Research and Behaviour Management. The title of the paper How can placebo effects best be applied in clinical practice? A narrative review, seems to create somewhat of a paradox. The usual definition* of a placebo is “a substance (or procedure) that has no therapeutic effect”. So, in a sense, the title of this paper could be re-written as ‘How can the effects of things that have no effect best be applied in clinical practice? A narrative review’!
In the clinic
Paradoxical titles aside, the authors suggest that there are certain principles that can be applied to enhance clinical outcomes, including:
– speaking positively about treatments
– providing encouragement
– developing trusting relationships between doctor and patient
– providing reassurance
– supporting relationships
– respecting uniqueness
– exploring values
– explaining basic mechanisms behind treatments
– communicating realistic, positive expectations regarding the outcome of treatment and the patient’s ability to cope with the disease and its treatment
– providing evidence about the efficacy of a treatment
– replacing negative suggestions with positive hints, for example, “here is your pain medicine” can be changed to “Here’s some medicine to help you get better”
-educating patients to ensure that they have a clear understanding of the treatment and the desired outcome
The authors suggest that there is evidence that these principles can have a powerful effect:
“Kaptchuk et al demonstrated this when they administered placebo without deception in patients with irritable bowel syndrome.48 They obtained placebo effects based on the relationship between patients and health workers. Further, they found that switching from a technical style to a more emotionally warm/empathetic style increased the placebo effects from 42% to 82%.”
When I read through the list above, I couldn’t help but think that it’s more than a bit daft that these principles were considered to have ‘placebo’ effects – even a brief reading of recent (psycho)neuroimmune literature will provide explanations (or at least well grounded theories) of the biological basis of the benefits of positive expectations, supportive relationships, health literacy and accurate conceptualisations of health, disease and recovery. Further, a modern understanding of pain, based on the notion that ‘we will experience pain when there is more credible evidence of danger to our body than credible evidence of safety’ (Moseley and Butler 2015) suggests that each of the listed principles could have a profound impact on reducing pain by providing powerful, credible evidence for safety (SIMs).
Time to let go?
Lorimer Moseley has suggested that the notion of placebo needs reconceptualising:
“The notion that placebo responses are responses that are evoked by nothing is nonsense… That a placebo response occurs means that something has changed the brain’s evaluation of whether or not to evoke that symptom. This makes a placebo response not a response to nothing, but to something we haven’t identified or measured.
Rather than interpreting “placebo” responses as mysterious unexplainable responses to nothing, we should, as the editorial hints, get excited about what else might have led the patient’s brain to conclude that the need for symptoms had just reduced. To suggest we should use the placebo response in clinical practice seems a bit daft to me because it is the other things (we are yet to identify, accept, or understand), which change the brain’s evaluation of the need for symptoms, that we should utilise.”
Suggesting that the ‘placebo effect’ be used clinically may well be daft, but treating a person experiencing trouble as a human being, providing up to date, reliable and relevant information, demonstrating respect, engendering trust and trustworthy relationships, and encouraging realistic hope seems like an eminently sensible approach in any clinical setting, don’t you think?
Maybe it’s time to let go, completely, of the notion of placebo. Perhaps an updated understanding of human beings means that this term is redundant, that there simply is no such thing as placebo? Thoughts, arguments, critical appraisals and even rants (as long as they are well thought out and referenced) invited in the comments below.
Moseley GL and Butler DS (2015) 15 Years of Explaining Pain – The Past, Present and Future, Journal of Pain (Accepted manuscript, ahead of press).
* there are multiple definitions for ‘a placebo’ or even ‘placebo effects’ but this is murky territory and, to be honest, this definition just fits so much better with the rest of the piece!