Placebo Effects and Paradigm Shifts

It’s rare to find an article in the traditional medical literature that I feel readers here may be interested in, so I hope you will forgive my extensive quoting of McQueen & St John Smith’s Guest Editorial in the February 2012 issue of International Psychiatry which arrived through my letterbox this morning:

Placebo effects may be simplistically defined as those accruing from taking dummy pills or inactive treatments. In placebo-controlled randomised controlled trials (PCRCTs) placebo is defined negatively, as those non-specific (typically nonpharmacological) effects to be subtracted from the treatment arm, to reveal the specific (typically pharmacological) effect. Here, placebo is “noise” obscuring the “signal” of “real” treatment. Recently, placebo effects have been defined positively as the specific effects arising from caregiving.

Systematic evaluations reveal that placebo treatments can have large effects, sometimes larger than the effects of properly evaluated “evidence-based treatments”. This is the “efficacy paradox”. The neurobiology of placebo effects (nuclei, pathways, neurotransmitters, peptides and hormones) is being mapped out. There is evidence for various psychological  mechanisms, including classical conditioning, evaluative conditioning, expectation (including the expectations of professionals), the quantity of care and attention received from professionals, and the quality of the therapeutic relationship or alliance.

Placebo effects are no less real or, in some illnesses, clinically important than the effects of direct biomechanical or pharmacological interventions.

Healing rituals occur in all human societies… The investigation of placebo effects and mechanisms has emerged as a way of studying the “healing situation”. The technological model of medicine seeks impersonal means of cure that can be applied independently of context and person. The PCRCT is a central tool of technological medicine. It developed precisely to control for interpersonal healing effects and individual and contextual factors. This approach has had spectacular success in the treatment of disease (the objective anatomicopathophysiology).

However, meaning, cultural context, interpersonal effects, personal preferences and values are enormously important in the treatment of illness (the phenomenological
subjective experience), particularly psychiatric conditions (Miller et al, 2009)…

Prescribing evidence-based treatments and simply expecting the technology to work while failing to establish therapeutic relationships profoundly limits clinical effectiveness.

As the guest editors go on to point out, the real challenge is therefore to encourage the development of positive therapeutic relationships. After all, the non-placebo, technological side of the equation is comparitively conceptually straightforward, if admittedly time-consuming and expensive to develop.

They suggest improvements in the training of psychiatrists. This is an important issue, but perhaps it is also worth highlighting that therapeutic relationships are hardly encouraged by the way modern medicine (including psychiatry) is structured and delivered, and there is also a limit to the efficacy of training for the subset of practitioners whose natural talents do not lean this way. There is a strong focus on “evidence-based” practice – possibly because it is very measurable and audit-able – with relatively little regard to the art of being able to talk to someone in a pleasant and productive manner, and think about what the conversation might mean.

The guest editors suggest that this positive way of considering the placebo effect means that we are approaching a paradigm shift in how we treat people. I hope so, but paradigm shifts require a critical mass of people to think differently, and I’m not convinced we have that yet.

The full issue of International Psychiatry from which I have quoted can be downloaded in PDF format from The Royal College of Psychiatrists

The Last Generation

Countdown to Singularity, Image via Wikipedia

Are we the last generation of humanity?

One of the unique aspects of human consciousness is a desire to understand the nature of our reality. This has manifested itself across all domains of life: spiritual, scientific, psychological, and philosophical. As a species, we are blessed with a deep dissatisfaction with whatever our current circumstances may be, leading to a drive to improve our quality of life. This has lead to the rise and fall of civilisations and religions across the ages. Distinct from this waxing and waning of interpersonal systems has been a much more steady rise in our technological sophistication. Of course there have been hiatus, often caused by an influx of newcomers into a rigid society e.g. the arrival of the Sea Peoples leading to Bronze Age collapse, or the fall of the Roman Empire due to political infighting during a period of external pressure from the Goths. Similar patterns can be detected in civilisations across the globe. But while the collapse of societal structures have delayed technological progress, they have never been able to fully press the reset button, and so sophistication accumulates.

It has been suggested that such progress is logarithmic, leading inevitably to the development of a technological singularity at which time mankind would be able to design an artificial intelligence greater than its own. Beyond this point, such superintelligences become able to improve themselves faster than man can understand, leading to an unpredictable and rapidly-evolving future. The idea is old, stretching back to the 19th century, but has received much greater attention and publicity over the past quarter-century. Theories abound as to whether singularity is possible, and whether the implications will be transformative or apocalyptic for humanity.

What is certain is that recent technological progress has done nothing to suggest that the theory is fundamentally flawed. Almost every day brings stories of startling new discoveries. For instance, it is now possible to read what another person is thinking, at least in a very rudimentary fashion. Is it really so far-fetched to assume that at some point, the technology to do so will be refined, miniaturised and made portable?

Consider your mobile phone, and how it would have seemed the height of science fiction even 30 years ago to suggest everyone would be routinely carrying around such incredibly powerful and versatile devices. It does not seem unlikely to me that such technology would continue to advance and become so integrated into our lives that it becomes integrated into our bodies, with displays directly interfacing with our retinas. Science fiction? Only just. There are already more than a dozen electronic prosthetic retinas in various stages of development and clinical trials, with an aim of restoring sight to the blind. While still primitive, money and time have a way of solving most difficulties, and both have been made available to these devices. The next obvious step would be using such technology to augment vision, instead of merely to restore it.

Even if we do not go down the road of cybernetic implants, it seems irrefutable that our degree of technological immersion will advance in other ways. Our entertainment systems, our cars, our phones, our very ability to acquire and process new information: all are already heavily influenced by electronic networks. It seems almost irrelevant whether they become physically part of us; they are already mentally – and emotionally – part of us.

The great hope of many transhumanists is that technological singularity and our increased integration with electronic networks will lead to a form of immortality, at least of consciousness. This has the vague air of eschatological myth, albeit built upon scientific hopes rather than religious ones. One might even describe this unconscious desire for ego dominance over death as a power phantasy.

I am not so convinced; everything I see suggests we are on a path to a very different kind of existence, with potential for a signifiant degree of self-actualisation within its broader scope.

Unfortunately, I do rather suspect the transhumanists are over-optimistic on the timeline. They suggest singularity sometime around the middle of this century or a little later i.e. within my lifetime, with luck and good health. I have a sneaking suspicion that it will arrive somewhat later. I will have to make do with other ways of seeking Jungian individuation.

Strange to think that my generation may be the last to need to do so.