Positive Health Online

What is the Placebo Effect?

Placebos have been traditionally regarded as deceptive therapies, often misunderstood in the broader context of factors surrounding the healing process. Although the power of inert substances to heal is recognized by some health professionals, how far does the placebo effect influence the outcome of healing in allopathic and complementary medicine? The role of the placebo effect in modern medicine seems poorly defined because of an apparent lack of common understanding of what it actually is, and an often negative connotation associated with its use.[1]

The placebo's response rate can vary according to specific illnesses, and other variables such as the natural course of disease, and patient or physician bias, which is sometimes misinterpreted as the placebo effect.[2] In research, the placebo effect is usually there to be removed, if possible, by placebo-controlled trials. There are few studies that have been designed to measure the placebo response rate directly, and placebos are a constant reminder about how little is known about mind-body interaction.[3]

Could the placebo effect be one of the most versatile and underused therapeutic tools at the disposal of health professionals both in the traditional and complementary fields?

How is it defined, and just how far does it influence the healing process in modern medicine, with particular reference to complementary therapy?

Placebo is Latin for 'I shall please', and in medical research it refers to a pharmacologically inactive substance, like a sugar pill, or sham medical procedure, that is administered for testing the effectiveness of a drug, or course of action.[1]

In the Beginning was the Placebo...

Until the discovery of modern drugs, medicine relied on the human spirit, and its powers of healing. In the beginning was the placebo, and, with regard to primitive medicine, that is virtually all there was. Early medicine and its cross-cultural cast of characters - shamans, witchdoctors, medicine men and herbalists - relied exclusively on scientifically unproven potions and procedures; the vast majority probably had absolutely no physical value, but because people believed in them, they worked.[4]

Health was a mysterious phenomenon. Illness was brought on by intangible internal forces; healers did what they could, but were often defeated by fate, leaving recovery in the 'hands of God'. Then, humanity began to eradicate the scourge of many diseases.[5]

During the twentieth century, scientists became the miracle workers, removing the threat of death, and producing cures of previously fatal diseases, such as diphtheria and tuberculosis. Prior to that, medicine mostly maintained the idea that disease was due to a natural imbalance - an interaction of physical, emotional and spiritual factors. Physicians believed in the power of the placebo, often giving patients 'bread pills', and water injections (which patients believed to be morphine), to act 'through the patient's mind'.[6]

The Advance of Medical Science

As medical science became more advanced, disease was believed to be due to a specific source, and medical science concerned itself more with treating the disease rather than the patient, thus moving away from individuality and the belief in the healing response of the individual.[3]

Originally, allopathic medicine had been as dependent on the placebo response (i.e. the patient's innate healing abilities) as alternative or complementary medicine, but when allopathic medicine became by tradition science based, it not only distanced itself from all other forms of healing, but from the idea that the mind might possibly influence the body, resulting in the placebo effect becoming disreputable.[6]

Clinically, then, the term placebo came to be regarded as a somewhat deceptive practice, and medical contemporary thinking has largely come to be dominated by thinking of the placebo in a negative sense, mainly because of the importance based on the double-blind placebo-controlled drug study, where the beneficial aspects of the placebo effect are noted, but then usually ignored.[2]

The placebo effect has complicated medical research ever since its 'miraculous powers' were rediscovered in the 1950s, when it became the 'benchmark' from which to measure new drugs and techniques. If the new medicine or drug was no better than the placebo control, it was considered a failure.

It did not matter that placebos could be very effective, or that they often cured. Medicine just concentrated on more aggressive forms of drug therapy, and the placebo effect was relegated to being 'all in the mind'.[7]

Could this be Changing?

However, this is beginning to change, and in health care the placebo effect is beginning to be seen as important, albeit complicated. Many people concerned with the holistic approach to health care are beginning to believe in its efficacy, and to feel that more research is necessary to investigate this phenomenon.[1]

Rees[8] has described the placebo, as a "medicine given more to please than to benefit the patient", and research has shown that the placebo can be as effective as the drugs being tested. As more techniques and therapies are being used that are dismissed by many as 'pure placebo', it is necessary to look more closely at some of these therapies, and how much of their success is due to this effect.

Thought patterns play a large part in the therapeutic effects of many complementary therapies, and studies have shown that emotional, mental and spiritual beliefs that have manifested as physical illnesses affecting the individual's health can greatly benefit from harnessing the placebo effect. If assuming that the aim is to return the patient to optimum health, then the belief is that the effectiveness of the placebo effect depends mainly on three aspects: the belief of the patient in the treatment offered, the practitioner's expertise, and the belief of the practitioner in the treatment being provided. It was found that much depended on the rapport between the patient and the practitioner, and the greater the rapport, the better the healing process.[9] Other studies have also found this to be the case in allopathic medicine.[1]

According to Smith,[9] if it can be assumed that there is some form of subtle energy present that can be converted into a positive belief that treatment will work, then it is essential that anyone concerned with healing and health care should take time to study and harness the power of the placebo effect.

He combines this with the necessity of trust, believing that everyone holds within themselves an innate power to heal. Combined with compassion and understanding, as well as a positive approach to life and a change of perception, he sees the use of the placebo effect as an essential part of the healing process, and indeed holistic health care.

Practitioner or Placebo?

Many practitioners assume that it is the treatment that they provide that leads to changes. It is their techniques that help the patient, and the effort invested by them in the requisition of their skills and techniques that leads to their belief in the efficacy of their treatment. However, when the change cannot be attributed to these techniques, they tend to be labelled as placebo, or spontaneous recovery, thus being made to appear less significant. Surely though, change is no less real if it is inexplicable; perhaps the non-technical factors contribute more to the healing process than is realized.[10]

According to Watts,[11] the placebo effect is always in evidence, and a significant part of the healing process. However, it must also be remembered that placebos can also alter symptoms negatively, thus creating negative side effects. This is the Nocebo effect. The expectation of harm can be extremely damaging, and, taking it to the extreme (death due to belief in a voodoo curse, for example), extremely powerful.

Rationally the placebo effect is both curious and puzzling; if the placebo being used is in the form of a medicine or drug, how can a change be incurred when the medicine or drug used to make that change is not actually present? Evidence would so far seem to indicate that its effectiveness is due mainly to the interaction between the practitioner and patient, and the belief that the patient has in the treatment.[10]

The sceptic's reaction to successful alternative therapy is often to cite the placebo effect as the main reason for success: "If you think something is going to work, no matter how 'hocus pocus' it is, then it will."[12] The sceptics also believe that the treatments are a return to practices used in the days before modern medicine; a retrograde step. It is also often argued by the medical profession that, in order to ascertain the influence of the placebo effect in various complementary therapies, this should be eliminated by double-blind controlled trials. Until this happens, complementary therapies should not be accepted within the medical profession.

But is it enough to assume that it is largely the placebo effect that brings about a healing response, particularly in complementary medicine? Are there other reasons for this exchange and the healing that takes place between therapist and patient?

Laying on of Hands

In the 1960s, studies were conducted by Grad into the energetic effects of healing; the successful cures brought about by the 'laying on of hands' were often attributed to the placebo effect - that both healers and patients relied extensively on the powers of belief. Grad believed that there were factors other than the placebo response involved, and conducted various experiments to try to distinguish between the psychological effects of the placebo effect, and the active effect of the energy present in the healer's hands. As the experiments were conducted on mice, the influence of any placebo effect was obviously negated. The results suggested that, as the mice treated by the healers healed faster than the mice in the control, this was due to a form of magnetic energy radiating from the healer's hands.[13]

Despite this, it is still very difficult to assess, with regard to healing humans, whether or not the placebo is in evidence, but the above certainly does raise the question of something other than just the power of belief - especially because there was no expectation of any healing taking place.

Homeopathy

Homeopathy is often challenged as being mere placebo, because the substances used are so dilute that absolutely none of the original substance remains. A recent article in the popular press has derided homeopathy as being mere placebo, and a collection of poisonous substances so dilute that people are being deprived of millions of pounds to buy what is essentially water, and a belief that something works.[14] The fact that it works for millions of people is regarded as something of a mystery. Or is its efficacy really down to the placebo effect?

According to Saks,[12] there is no pharmacological basis for the fact that homeopathic remedies work in themselves. Homeopaths claim that the process of dilution and succussion affects "an immaterial and vital force" (p219), and that this is the basis of homeopathy. However, no scientific evidence could be found for this belief; what was evident was a very positive and valuable self-healing effect (or placebo), which was transferred to the patient because of the way the dosage was administered. The regime and appearance of the medicine invested it with special properties, and, coupled with the belief in the homeopath and the 'sugar pills' of homeopathy, this is what produced the healing effect (also mirrored in allopathic treatments). Saks believes that it is the placebo effect which provides the cure in homeopathy, and that usually conditions that are treated and cured by homeopathy would have probably got better anyway.

However, in a study headed by David Reilly, it was found that homeopathy was superior to the placebo in an inexplicably reproducible way. Twenty-eight patients were divided into two groups, half given homeopathic treatment and half placebo. The results were astonishing. While approximately one-third of the group given the placebo improved, 80% of the group given the homeopathic medicine got better, and stayed well for a further eight weeks.[15] This result must be indicative of the efficacy of homeopathy; surely, though, it is still impossible to negate the effect of the placebo response altogether, because so many of the control group also improved, and there is no real way of knowing whether this was also present in the group given the homeopathic treatment! Could the intangible placebo also have been present?

Castro[16] states that homeopathic remedies are often believed to work because of the placebo effect, but they also often work effectively with babies and animals, neither of which is open to suggestibility. With homeopathy, it is essential to individualize the remedy to fit the patient and not the disease, to ensure that the underlying principles are observed and the element of chance decreased. Of course the practitioner must also inspire belief and hope, but this rapport must, according to Castro (p38), also be backed up with the correct prescription for the person concerned, and if this is not the case, then "no amount of positive transference will cure the patient".

Acupuncture

At first, medical practitioners believed that the success of acupuncture was due solely to the placebo effect, but gradually other explanations have begun to emerge, and there is growing acceptance of acupuncture as an acceptable treatment in its own right. The energy meridians and acupuncture points are invisible; if they exist, as far as we are aware they do not correspond to any known anatomical entities. Although critics dismiss acupuncture as mainly placebo, it is now known that acupuncture triggers a significant release of endorphins and encephalin - natural painkillers that can promote healing and remove depression.[17] However, can placebos also stimulate the production of endorphins? In studies of patients following the extraction of wisdom teeth, the effect of the placebo was found to be equivalent to eight milligrams of morphine![18]

The development of placebo-controlled trials has undermined the use of inert placebo medications, as has the view that harnessing the placebo effect was considered to be ineffective and unethical. This led allopathic physicians to argue that complementary medicines only affect subjective measures of disease activity, through the placebo effect, and are therefore of limited benefit.[19]

Cure or 'Blind Faith?

These arguments do not really ring true, because, according to Watkins,[20] expecting to recover and promoting a placebo effect is different from subjective improvement. It is possible to feel better without the expectation of full recovery. It is also possible to recover without feeling better; therefore complementary therapies cannot be dismissed as mere placebo. It is often said that it is the patient's blind faith in complementary treatment that brings about a cure, but practitioners also give their patients an insight into new areas of health and healing, and a greater insight into their own health. Blind faith cannot simply explain away all the positive effects of complementary medicine. Patients often use complementary therapies as a last resort, and, although they have not received satisfactory help from the medical profession, often still maintain faith in medical doctors; and despite turning to alternative practitioners, this does not necessarily mean that they anticipate a 'miracle cure'. Therefore, from this angle, the success of complementary therapies cannot be explained away by pure placebo. The rapport between patient and practitioner is likely to be one of the major reasons why the treatment works - both therapist and patient co-operating in the process of diagnosis and treatment, thereby creating an individualistic or holistic approach and triggering off the healing process, helping patients to mobilize their own power in order to help heal themselves.[21]

How much of the placebo effect is actually involved is difficult to assess, but if the patient is encouraged to believe in the treatment then it probably does make it even more effective. It is often looking at treatment from a new perspective, creating a form of order in the chaos caused by sickness in the personal lives of patients, and providing some sort of meaning to the illness and the treatment, that assist in the healing process.[22]

Is the Placebo all it Seems?

So far, the existence of the placebo effect has been accepted without question as a phenomenon that does exist. However, is the placebo effect all that it seems? There are some factors that may not have been considered when discussing the power of the placebo; could it be possible that much of what has been written about the placebo effect over the last 50 years is myth? Kienle and Keine[23] believe that it is possible that not all research concerning the placebo effect has been properly conducted, and that other variables should be taken into consideration. They believe that the placebo concept cannot be logically defined, and therefore leads to contradictions. Also, the use of the term placebo tends to be applied to all modifications of self-healing properties, particularly complementary and psychological therapies.

There are also factors that can create illusions of placebo effects, such as natural spontaneous improvements - people do get better naturally; in chronic diseases such as arthritis or angina, there can be fluctuations of symptoms due to other variables. The people who get better in placebo trials are noted, but the patients who get worse are often not; in many trials, patients received additional effective treatment, such as professional support, and there is evidence that patients will report improvements just to please doctors, or to be polite.[24] Because patients are grateful to the health professionals for help, they may often exaggerate the benefits of a particular medicine by saying what is expected rather than what is experienced. This can create an illusion of the placebo effect.[25] Patients who suffer from neurotic or psychotic illnesses are often not reliable in reporting correct observations. Also how do we know that the placebo itself (if in the form of medication) does not contain beneficial components, and that it is completely inert? There has therefore been an assumption that an inert pill can have therapeutic effects in what is usually quoted to be about a third or more patients in a variety of conditions, and this healing power of the placebo has been considered to be a scientific fact for the last 40 to 50 years. The power of the placebo, then, could be grossly exaggerated, because of these and other variables that have possibly not been taken into account.[23]

The Emergence of Psychoneuroimmunology

However, taking this into consideration, there is scientific evidence accumulating that suggests a definite physiological link between mind and body.

Cartesian dualism has always made a distinction between the body and the mind. The reductionist view is that they are separate, and the focus is on the disease as separate from the person - that disease is a biological phenomenon, and pathological in origin. Therefore, the body is treated as a separate entity - an object separated from the mind. Developments in psychoneuroimmunology are beginning to demonstrate links between the body and the mind; for example, links between stress and illness,[26] and that stress manifesting itself in physical illness can affect the immune system within the body. Evidence is accumulating about the ways in which psychosocial factors are related to immune functions, and the body's ability to fight disease. There have been instances of recoveries brought about purely by faith, expectation and the power of the mind.[27]

Is this part of the placebo effect? Visualizing an outcome that is thoroughly believed in? Is this what all health professionals should engender in their patients, and themselves as well? No matter what the treatment, patients are often encouraged by health professionals to take a passive role in their treatment, to follow instructions, and to be compliant. In fact, patient compliance is often a very large issue in both psychiatric and physical medicine. The patient may expect and hope to be cured, but wants, or is encouraged, to allow the doctor or therapist to take the responsibility. Maybe health professionals are either not aware of, or are too frightened to encourage and utilize the patient's potential for self-healing, thus encouraging patient participation in the healing process by relinquishing some of the responsibility to the patient.[6]

Some people when diagnosed with life-threatening illnesses give up, and illness becomes the focus of their lives. Others are willing to do anything to heal, and acquire an attitude and a practice of envisioning themselves well. They take charge of their lives as a result. It does not always provide a cure, but can sometimes enhance the quality of, and also prolong, life; if beliefs and expectations can have biological consequences, so can attitudes, and there is increasing evidence that attitude of mind can affect biological functions in various ways.[27]

This relatively new field of psychoneuroimmunology affects not only the immune system, but also the glandular and nervous systems, in ways that might affect recovery from disease.[28] If thoughts, emotions, desires and beliefs are physical states of the brain, then there is nothing mystical in the notion that these neural processes could affect glandular, immune and cellular processes throughout the body. Via the limbic system of the brain, the hypothalamic pituitary axis and the autonomic nervous system, psychological variables can have widespread physiological effects that can have positive or negative impacts on health.[20]

Is Encouraging the Placebo Response Deceitful?

How does the placebo effect relate to the brain immune pathways? It has been argued that the placebo effect is involved in every therapeutic intervention, whether allopathic or complementary, and that even the relief gained by taking painkillers is also due in part to the placebo response. So why do most allopathic practitioners consider it deceitful to encourage actively the placebo effect?

This unwillingness could perhaps be due to the unpredictable and unreliable nature of the placebo; it has been difficult to measure because of the belief that it is caused by unspecific mechanisms.[20] However, research into mind-body medicine is beginning to prove that if a patient believes that a recovery will take place, then the feeling of well-being that this imparts actually activates the autonomic nervous system, and effects pituitary hormone production. Therefore there are pathways that can be tested. This expectation of recovery, or placebo effect, can alter the immune system, and it is probable that in some susceptible people can produce large shifts in autonomic balance. (However, it must still be remembered that, in others, only minor changes occur, and this could lead to unpredictability.)[29]

Therefore the 'brain immune pathways' could regulate the placebo effect, and complementary therapies may either promote a placebo effect leading to a cure, or may just activate brain activity without involving the placebo effect, because individuals are different, responding to different stimuli in different ways. Complementary treatments will have different effects on different people, and will work more efficiently for some than for others. However, an excellent example of the efficacy of a complementary therapy, as opposed to the placebo effect, was shown by the aforementioned homeopathic study, where in this instance it seemed quite clear that homeopathy outperformed the placebo in a double-blind trial.[29]

A Belief in the Power to Heal

There does appear to be some evidence to support the fact that the placebo effect could influence healing in modern allopathic and complementary medicine. If there is absolute belief in the efficacy of a treatment, then it will often work. If this is the case, then why do so many health professionals seem determined to rule out the placebo effect?

It would seem that some health professionals and complementary therapists tend to have a negative attitude towards the placebo by trying to negate its effect, believing that it is necessary to prove that it is the medicine or therapy that works of its own volition. This attitude is rather strange, because surely the placebo effect, or 'power to please', is also involved with a belief in being healed. The belief that a person can trigger a healing response, and produce a beneficial effect without harmful drugs or treatments, should surely be regarded as a very positive sign. Maybe the reason is that the placebo effect is not as yet fully understood, or maybe it is still because of the belief that the body and mind are separate - the old 'Cartesian dualism'.[30]

Psychoneuroimmunology is perhaps beginning to point to a deeper understanding of the nature of healing, and maybe in the future the placebo effect will become a recognizable, accepted and important part of the healing process.[21] Surely the most valuable treatments are those that are the most effective, but which cause the least harm. If it is possible to harness the power of the placebo to influence and unblock innate healing responses in the body by using techniques that harness the power of the mind, then surely this has to be medicine at its best. Maybe it should be viewed as a way to maximize the benefits of medication and other treatments, to improve and maintain health. The placebo effect could be a positive force in recovery from illness, and as complementary therapies in particular are seen as holistic, then the practitioner that can effect healing from within is surely practising holistic therapy in its purest form.

References

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