What does the placebo effect have to do with psychotherapy – other than to cast doubt on its validity? The placebo effect is the tendency of people to get better if they think they’ve been given medicine or treatment to ‘cure’ them, even when all they’ve gotten is a sugar pill. The public equates the term ‘placebo’ with ‘It doesn’t really work, it’s all in your head.’ In pharmaceutical studies, it is a ‘noise’ factor as well as a bar of sorts: if your drug doesn’t out-perform a placebo, it’s no good.
But there are a slew of scientists who are studying the placebo effect, and its sinister counterpart, the nocebo effect (you’ll get worse if you think you’ve been given something harmful) to learn how to improve health care.
So I started thinking about what the placebo effect findings suggest for the field of psychotherapy, and I was surprised at how relevant placebo research may be.
Let’s start by being clear on what placebo effects can and can’t do. They don’t shrink tumors or cure viruses; the placebo effect isn’t evidence for the ability to ‘think yourself well.’
So there is no ‘placebo effect’ for cancer treatments, HIV treatments, even asthma care. But placebo treatments trigger real brain changes and physiological responses (heart rate, bp) in conditions involving depression or anxiety, fatigue, and chronic pain. Does this mean those conditions are not ‘real?’ No, but it suggests that conditions involving mood and internal experience of pain are particularly subject to placebo impact.
Well, as a therapist this pretty much describes what I do – help people respond to depression, anxiety, exhaustion and stress, and pain. So figuring out what works in the placebo effect might help a therapist enhance their own personal impact as a ‘placebo.’
When researchers deconstruct what happens in a placebo experiment, there appear to be many factors at play. Some involve reporting bias: the subject doesn’t really feel better, they just want to please the experimenter by reporting improvement. Every therapist experiences this some clients who do this, and we hope to be able to see through it. Another factor is that the conditions most vulnerable to the placebo effect tend to get better with time, for many people, with no treatment at all. What this means is that time is often on the side of therapy.
It has often been claimed that the placebo effect depends upon deception and a blind belief that the treatment will work. And yet when participants are TOLD they are being given placebos, they improve just as much as when that fact is hidden.
Clearly, there is more at work here. One important study done by Ted Kaptchuk at Harvard showed that subjects who received the most personal attention from their doctor responded most to placebos, suggesting that it is the caring connection that spurs improvement. And a study of asthma patients showed that those given placebo did not improve by physiological measures – but subjectively experienced improvement.
That study provoked criticism by those who pointed out the risks of believing you are improving when you are not, and other criticism of placebo research has focused on the fact that the effect seems to be short-lived and may not be as important as believed.
But psychotherapists work with ailments where the belief you are improving may give you the motivation to, say, work harder on changing yourself and your life. And this hard work pays off in terms of REAL improvement. Moreover, even if this effect is short-lived – it may last just long enough to get a client out of the inertia of despair and into productive action.
What does this imply about therapists? It implies that our own caring about a client, and the time we spend with that client conveying our concern, may be, at least at the beginning, the most powerful tool we have. And it speaks to the wisdom of pushing rather quickly for change, rather than taking a long time to assess a problem thoroughly. If placebo effects are short-lived, as a therapist I want to strike while the iron is hot. Every seasoned therapist knows that timing can be everything in the process, and that’s it’s all about turning around a self-perpetuating negative downward spiral. Once you’re facing upward and moving in the right direction, that movement becomes self-reinforcing. Your positive change motivates you to work harder for more improvement, and the force of inertia eventually turns to a powerful forward and upward motion. For a therapist, harnessing the power of placebo means catching hold of the ephemeral forces of positive change.