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.