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.
Chris..please read my new book “Thank God I’m a Sucker” ( publish by Authorhouse) for a detailed review & new theory about he placebo effect, which I prefer to call “Ipsicura”.
Dinesh
Thanks Dinesh. Ipsicura? Or ipsi cura, as in the Latin for “he shall care his self”? Interesting choice of symbolism!
(sorry if I mistranslate, my Latin is very very rusty these days, haven’t done it since school…)
Hi Chris, thanks for flagging up this interesting item. It inspired a couple of thoughts, I apologise if they’re half-baked or misinformed; it occurred to me firstly to think of Ben Goldacre’s writing on the placebo effect, and more specifically the nocebo effect, or the ability of a drug or non-drug to cause harm simply through pessimistic expectation on the part of the patient. I then connected this with another thought inspired by a historical thought about the ‘healing rituals’ prevalent in all human societies, and examples of historical medicines used by various cultures or groups, and employed in different historical circumstances.
The outcome is a question: how far is the subjective healing power of modern medicine (its ability to actually make a person feel better) connected with expectation and the prevailing culture of the efficacy of scientific medicine? The flipside of which is: when certain healing techniques were used in the past, at which we might now scoff, could they be efficacious due to this same effect? Of course their continued use within those societies is no proof in and of itself of their objective success (people sometimes get better; theories can be given priority over evidence), nevertheless, might what success they achieved be due to an accordance between the beliefs of the patient and the values of the system of medicine being applied?
The final point then, is to wonder whether treatments should be more accommodating of individuals’ beliefs, regardless of whether the practitioner shares them. Or should an individual seek out a practitioner who does share their beliefs? Does this result in a higher success rate or greater subjective health benefits? Would this apply to both mental and physical health equally? I wonder how this idea would be manifested in practice?
I would be interested to hear your thoughts on this, thanks again!
Michael.
Interesting questions, Michael. I don’t know if I have answers, but I have some ideas.
There’s a commonly cited statistic that about 30% of clinical efficacy of any medical intervention is placebo effect. In reality, it varies by the nature of the intervention, the person receiving the intervention, and the implicit social contract at the time when the intervention is delivered. The point I’m making with this paragraph is that psychic effects have always been important: we are, after all, talking about making people feel better. Not just about eradicating the pathophysiological markers of a disease entity. On a slightly abstruse philosophical level, people are ill not because of the physical illness but the effect of that physical illness on our sense of well-being. This matters because modern medicine has had a tendency to focus exclusively on the physical markers of illness, not necessarily on their impact on our sense of well-being.
The atmosphere of the society within which treatments are developed/given affects their efficacy. A very physicalist society will find more benefit from physical interventions; a more spiritual society will find a relatively greater proportion of benefit from the non-physical aspects of the intervention. Take that generalisation into more specific territory and you can have a a valid debate about whether health care should be tailored to the belief system of the individual or whether it should be delivered according to the prevailing norms/beliefs of the society in which it operates.
This philosophical tangent has particular implications in the UK as we fund health care out of general taxations and so the State can legitimately argue that it has a duty to ensure it is delivered according to its own national societal defintions. In fact, it does exactly this, through institutions like NICE, charged with determining whether new interventions are cost-effective or not. Some of the changes in the new NHS bill currently wending its troubled way through Parliament will shift some of the burden for this decision-making to a smaller, more local and perhaps even individualised level. You can decide for yourself whether this is just, or not.
Privately-funded healthcare allows for a greater matching of practioner belief vs patient belief. Whether this is good or bad depends on your perspective on what the healthcare process is all about. Is it about well-being, about correcting physical markers of illness, or about satisfaction with the process? These have areas of overlap, certainly, but by no means are they all identical to each other!
There’s a lot to think about here, thanks!