This is a really important topic which I hardly dealt with in the book. It’s one that scientists don’t really like because in many respects it’s not measurable and it belongs more to the mysterious realms of psychology, mind/body studies and psychosomatics – all pretty scary for medics.
But it’s scientifically and therapeutically very important. In some respects, it really ought to be categorized under ‘treatment’, because any action, including what seems like no action or neutral action, always has some direct effect on health and welfare and is not, as commonly assumed, actually neutral or empty at all. The giving of a sugar-pill or even a diagnosis itself have no pharmaceutical or surgical components, but either may affect the physiology and/or the psychology of the recipient in important ways.
We’re probably most familiar with placebos in double-blind clinical trials where the effect of an active pharmaceutical substance is tested against the effect of an inactive pill by researchers and patients, none of whom knows who is receiving what. Results may show that the active substance has more therapeutic effect than the placebo (though this is not always the case), but it is very rare for the placebo to have no effect, and common for a placebo to have more effect than no treatment at all. Medical literature is thick with accounts of patients feeling better or getting better for no apparent medical reason at all: the placebo effect? Almost certainly, except for natural recovery and spontaneous remission (which may themselves be influenced by the placebo effect, of course).
There are even evidenced records of placebo surgery:
…a team of physicians discovered that sham arthroscopic surgery (in which the surgeon makes an incision but no instruments enter the knee joint) worked as well as real surgery for patients suffering from osteoarthritis.
[Quoted in Markle and McCrea, What if medicine disappeared? p. 54]
What does this startling phenomenon tell us about the nature of being human? It tells us something very obvious, and something we should know even without the specific evidence of the placebo effect: people are integrated organisms in whom body and mind are inseparable, whose feelings affect their bodies as much as their organs affect their feelings; in whom, to a large extent, the duality of ‘mind’ and ‘body’ is an unhelpful and distorting myth. We know this: people who are happy are less prone to illness and recover more quickly from it than those who are miserable; the emotionally vulnerable suffer greater morbidity than those who are confident, optimistic and independent. Psychological state almost certainly affects the robustness of the immune system and all the body’s defenses. Expectations influence how people feel and what happens to them.
Nothing but this can explain why an inactive pill can make people better. It is not, of course, the intrinsic qualities of the pill which have therapeutic effect, but the transaction in which the pill is given. If the patient believes they are being given something useful, their body is prone to respond as if they were being given something actually useful, triggering, presumably, self-healing mechanisms which were always available without external intervention (the release of dopamine is one example). We can assume that the potential impact will be greater the more the patient trusts the giver; the more the context of receipt is convincing; the more positive the expectations are. It’s the human transaction and the patient’s belief which produce the healing effect. (There’s evidence that even the colour of a pill may affect patient’s expectations of it and physiological response to it.)
Not much talked about, but equally important, is the nocebo effect – the extent to which patients may suffer negative effects for no apparent scientific or physiological reason. Perhaps the commonest example of this is the patient who has some investment in being ill with accompanying low expectations of treatment, whose rationally prescribed therapy has little or no effect, or negative effects. It is said that patients who are worried or obsessed by the possibility of particular disease or adverse reactions are much more likely to become sick or experience pain than those who think less about such things.
We cannot doubt that the impact of a relationship with an HCP can be positive or negative, on a scale from healing to damaging, according to the quality of the personal care and communications offered – irrespective of pharmaceutical or surgical intervention. That is why, earlier, I included diagnosis as one among many aspects in discussion of the placebo effect: the very way in which a disease is identified and communicated will certainly affect the feelings of the patient, and may, therefore, possibly affect the course of the disease and how the patient deals with it. We might hear talk of the ‘placebo effect of diagnosis’ – but that’s nonsense, because while it may be pleasing, it’s also intervention.
The issue of diagnosis highlights the inadequacy of the concept of placebo, and the absurdity of the disease model of medicine:every element of interaction with a patient has content and meaning and has some effect on the whole person. Giving an active or inactive pill, providing a diagnosis, are not neutral, empty, mechanical processes: they take place within a relationship, and can be done warmly, coldly, effectively, briskly, confidently, cynically – and in a thousand other ways. Those ways will affect the patient directly, to a greater or lesser extent, irrespective of the message or the treatment bring given.
Placebo’, in its common usage, is an inadequate concept because it refers only to the physical substance and ignores the quality of the transaction in which the substance is given and the expectations raised. How much of the positive effect of an active substance given in clinical trials results from the effect of the transaction in which it is provided and the belief of the patients in the beneficent intentions of the researchers?
This whole issue is, of course, at the very heart of my book, and underlies the obsession with relating with patients as whole people, not as carriers of disease states to be treated. The relationship is a critical, inescapably influential element of any treatment and, in some situations, may be the only treatment needed.
There’s an interesting allied effect of expectation from 1950s industrial sociology, known as the Hawthorne effect: in this, a group of workers being observed and researched, increase their productivity as a result solely of the attention given them while being studied. If you study the behaviour of a group of people, unless you are very clever, your research will change how they behave and your study will record behaviour which is different from what would have occurred had you not been there. The change may last only for the period you are present, or slightly longer, unless the changes are somehow embedded in new structures, rules or expectations. Patients too, we know, may be co-operative and compliant while we are around, but then go off and do entirely their own thing once we are out of sight.
There’s a lengthy and very intelligent review of the placebo effect and several related effects of expectation in: The Hawthorne, Pygmalion, Placebo and other effects of expectation: some notes, by Steve Draper at:http://www.psy.gla.ac.uk/~steve/hawth.html#placeb
Lots more on the Hawthorne effect at: http://www.12manage.com/methods_mayo_hawthorne_effect.html
Tags: Placebo