Placebos are usually defined as inert substances, but in fact there’s nothing inert about a placebo. As soon as the patient puts the tablet in her hand or rolls up her sleeve for a shot or looks at the round face of the doctor, wearing wire-rimmed glasses, magic begins to happen. That inert sugar tablet becomes like the mezuzah that graces the doorway of believing Jews. That needle shimmers with luxuriant light. The face of that doctor has about it a gravitas, such that even the cleft in his chin is a sign of profound wisdom. All of this meaning – all of these symbols and the sense they make to the person in pain – comes directly from some portal within. The placebo is a key that unlocks our endogenous opiates, part of our complex immune system which shakes itself out and gets down to work, finally. The placebo is the push we need to step over some threshold, dragging our body behind us, and once we’re on the other side, healing begins.
Psychotherapy, of course, is not a sugar tablet, a needle, a scalpel or a laser. It cannot be contained like a tonic in a bottle. But who says placebos must be actual objects, with weights and measures? Cannot the face of a handsome therapist with the golden seal of his diploma hanging authoritatively on the wall reassure the patient? Cannot a glance between therapist and patient be a salve in its own right? It can, and it often is.
Psychotherapy comes in many different styles; in the United States they have more than four hundred different kinds of treatment, leaving out entirely the shamans and exorcists on the other side of the seas. There are also numerous therapy options in the UK. There is psychodynamic therapy, where you explore the way your past pollutes your present. There is Gestalt psychotherapy, where you speak to your loved ones through role-playing you do with your doctor. There is cognitive behavioural psychotherapy, where you learn to restructure your negative thoughts. There is dialectical behavioural therapy, philosophical therapy, Freudian therapy, Adlerian therapy, so many different schools and such a splatter of approaches that one wonders how to choose.
Given the almost absurd plethora of treatment options, it may come as some relief to know that studies have more or less definitively shown that you can pick any school of psychotherapy that you like, whether on the NHS or available privately, because all the different kinds of treatments yield pretty much the same result. Yes, that’s right. Research demonstrates that not only do all schools of psychotherapy seem to work but also that they all work equally well when it comes time to tally the points. No matter the school, those who receive psychotherapy of some kind are on average more psychologically well than 75 per cent of people who don’t, an outcome that suggests, if you don’t want to wait for a referral and if you happen to have extra cash to spare, a private psychotherapist might not be a bad investment.
In fact, research shows that even the slackers who come only a few times still make some gains from having given therapy a go. That’s because the very act of disclosure appears to have a profound effect on health and well-being. In the 1980s researcher James Pennebaker, a psychologist at Southern Methodist University in Texas who would one day be tapped by the FBI to study al-Qaeda communications, organised a series of disclosure experiments with university students. Of the two groups he studied, the first was assigned to write about ordinary everyday events, to describe, for instance, the laboratory where they were writing, or the act of washing and drying their dishes. The other group was told to compose a story about a traumatic event in their lives. Participants in this second group became deeply invested in their stories, the prose powerful and compelling, and many cried as they were scribing. The stories they told had a hold on the reader because they were so genuinely felt. This was not the most striking outcome, however. Pennebaker followed up with the two groups of students after the experiment had concluded, checking to see how often they visited the university health services in the months following the writing assignments. The students who had written about a trauma, it turned out, went to the clinic less frequently than did the students who had written about mundane details.
When this experiment has been repeated with different subjects and in different countries – from New Zealand to the Netherlands and from Belgium to Mexico – the results are always the same. Disclosure itself has a protective effect on health and well-being. This is likely why psychotherapy of any and every kind helps the majority of people. It has nothing to do with the techniques of the clinician and everything to do with the stories the patient chooses to tell. That’s partly because merely pondering the events of our lives doesn’t provide meaning or psychological growth or health. It’s when we use ‘causal words’ – such as ‘because’, ‘cause’ and ‘effect’ – that we get to the root of things and show improved health as a result. Our own words are the potent tablets. Our own words strengthen our immune system, tamp down inflammatory cells and release endorphins in our brain, thereby allowing us to live well.
Here, in fact, is how little the particular clinician performing the treatment matters. Research demonstrates pretty convincingly that you really don’t need a psychotherapist at all to get the benefit of the talking cure. This is probably hard to hear if you spent, say, seven years on your doctorate, plugging along so that you would have the right to grace your last name with those three esteemed letters, the capital P and the lowercase h followed by the capital D. But one study showed conclusively that the correlation of the effect between the experience of the therapist and the therapeutic outcome was 0.01. Other studies have also had similar results. In other words, effectively zero. No relationship whatsoever – a result that has been confirmed many times. Your next-door neighbour Bill or your Aunt Jo would likely be just as effective a therapist as that Sigmund Freud lookalike you’ve been making appointments with.
How can this be? Another 1979 study done with university students – this time a group of disturbed individuals – illuminates the conundrum. In this study, researchers sent half of the students to highly skilled therapists (with twenty-three years of experience on average) and the other half to kindly university professors of English, philosophy, history or mathematics. The professors were chosen for their radiant warmth, their wit, their engaging personality styles and their seeming willingness not only to draw a person out but also to listen empathically. The researchers also had two control groups, one of which received no treatment at all, while the other received only minimal treatment. Not surprisingly, the students who received up to twenty-five hours of discussion with a therapist or a professor did significantly better than the control groups, but there were no significant differences in outcome between the group who saw the premier therapists and the group who saw the kindly professors. The researchers attributed the positive change in the students to ‘the healing effects of a benign human relationship’.
It’s something about warmth. About connection. Something about the process of making meaning and myth with another person who cares. This can salve the suppurating wound of panic, can warm the chill of dysthymia. We live in an age when it would be an understatement to say that medication is in style, what with one in every eleven British adults popping antidepressants for syndromes we can’t quite call diseases because we have no affiliated diseased tissue to show for our psychiatric state. But while the pathophysiology of mental misery is far from being understood, no one doubts it is real.
Almost four centuries ago, René Descartes hypothesised that the soul was located in the brain’s pineal gland, a tiny structure in the shape of a pine cone lodged deep in crenellated paste. By separating the soul into its own space, Descartes gave birth to the mind–body problem. But no one really thinks any more that there are two separate entities known as mind and body. We know – do we not? – that we are all body and that being all body is an astounding, miraculous, never-ending curiosity and weight. We know that all our tangles of emotions, whether arising from seeing a sunset or contemplating suicide, are neurochemical phenomena. It’s all about synapses and liquids coursing through our heads. And yet these very real, very visceral human hurts can be healed by a
gentle hand on top of our own, by a maths professor who likes to listen. Something about the telling of stories can make our miseries bearable, and is this not in essence what a placebo response is? ‘Placebo’ comes from the Latin for ‘I will please’ and when our maths professor puts down his chalk and sits in his rumpled suit and listens with his head cocked slightly to one side, the person on the other side is pleased. He is placeboed. And he is helped.
A placebo is not just a sugar tablet or a bunch of sham sutures. A placebo can be an event as well as a thing. Anytime a person endows something with meaning, whether it’s a relationship or an occurrence, he is held in a warm embrace; he is helped by something that does not exist except as dream or hope or expectation. Much of the power of the placebo comes from the one who is hurting, which means we can start to see the sheer energy in states of sickness – what we are capable of doing when down and supposedly out, how strong we really are, even in our weakest moments, with our brain always ready to find us some faith.
Nocebo
It makes sense that if the power to heal comes from within the walls of our own bodies, then so too does the power to hurt. Consider the strange story of a 26-year-old man enrolled in a double-blind clinical drug trial aimed at testing a novel antidepressant. The subject did not know whether he was receiving the inert capsules or the real thing, although events suggest he believed he was taking the actual antidepressant because one day he overdosed on his capsules, taking twenty-nine of them, after which he became quite ill and his blood pressure fell so steeply that at the hospital he required intravenous fluids. Once the man understood, however, that he had overdosed on the dummy capsules and not the real thing, his adverse symptoms immediately reversed and he was fine.
This is not a singular sort of story. There are numerous accounts of voodoo death in indigenous cultures. For instance, in William Brown’s 1845 ethnography of New Zealand aborigines, there is the tale of a Maori woman who ate fruit she was later told had been taken from a tabooed place. The woman then believed that she had somehow sullied the holiness of the chief and that she would die as a result. Sure enough, within a day of eating the fruit, the woman was dead. In another account, in North Queensland in Australia, a well-known witch doctor in the area pointed a bone at one of his fellow natives who had become a convert at the local mission. The young man, now serving as the principal helper of the missionary, subsequently became weak and then actually ill and in anguish. When a doctor was called to examine him, he found no fever, indeed no signs or symptoms of any disease, and yet the young man was in great distress and was clearly wasting away. Once the doctor learned that the witch doctor had pointed a bone at the young man, he sought out the witch doctor and threatened to cut off his food supply unless he reversed the spell. The witch doctor immediately agreed to go see the young man and, upon visiting his sickbed, assured him that no harm would come to him, that it was all ‘a mistake, a mere joke’, whereupon the young man instantly recovered.
Voodoo death is a form of what is called nocebo, a phenomenon that shares many similarities with the placebo; in fact it is the placebo, only turned totally around. Like ‘placebo’, the name comes from Latin, and means ‘I will cause harm’, although that would be putting it lightly, given that the nocebo phenomenon can kill you just as surely as a bullet to the brain. Nocebos show once again the power of human thought to completely affect our somatic systems. Researchers believe that nocebos precipitate a slew of toxic hormones in our brains and bodies such as the stress hormone cortisol, which can kill in excess, and adrenaline, which shares some similarities with forms of speed and can also kill in overdose. The mixture of these harmful hormones creates a cocktail that can cut the lifeline short. Nocebos and placebos, it turns out, reveal a lot about not only the role of expectation, faith, fear and belief, but also the extent to which our bodies are themselves pharmaceutical factories producing psychoactive drugs in considerable quantities.
Nocebos are about the incredible power that lies within the borders of our bodies, the power to heal and the power to kill. This power is also, however, social in nature; it belongs to each of us individually, but it is activated by interaction with others and illuminates the significance of contact and connection. Our lives cannot be lived in isolation, or at least not fully. All primates are social creatures. In fact almost all animals of every kind are social creatures, but Homo sapiens may be the most social of all. Consider this: when a newspaper releases a story about a suicide, the suicide rate can suddenly rise. Marilyn Monroe committed suicide in August 1962. The suicide rate spiked by 12 per cent in the month following her death. Similarly, when a fatal car accident is reported in a widely circulated newspaper, the number of car crashes increases in its immediate wake.
Perhaps the most dramatic example of this odd kind of human contagion occurred during the deadly dancing plague of 1518, in the Alsatian city of Strasbourg, which had been suffering from famines, a series of them rising out of bitterly cold winters and scorching summers, the sun pounding in a sky white with heat. Before the deadly dancing plague began, the city was in distress of biblical proportions, with sudden hailstorms pelting its citizens from clouds cracked open as if by the grasp of God himself. It’s easy to imagine the citizens of Strasbourg as frayed, in extremis. And then, one July during this duress, a woman named Frau Troffea suddenly began to dance fervently in the street. She danced for four to six days straight and then was taken away to a shrine. At that point, others began to dance, putting down their satchels of baguettes and apples, the detritus of their lives, dancing by both daylight and moonlight. At the end of the week, thirty-four people had joined in and were dancing up and down the street. From there the contagion grew. Within the month, more than four hundred dancers filled the city, moving as if struck by a spell. Some died from heatstroke, others from heart attacks or exhaustion. Still the dancers twirled around the fallen bodies, unable or unwilling to stop even as more fell and more joined the ranks of the dead.
As the plague worsened, concerned nobles brought in esteemed doctors. At first they blamed astrological or supernatural causes, then ruled those out and attributed the deadly dancing plague to ‘hot blood’. Perhaps because it would have been impossible to bleed hundreds of people in perpetual motion, the village authorities decided on a quite different treatment. They would instead encourage the dancing, bring it to its apex in the hope that, once it crested, it would dissipate and recede, like a wave crashing and washing out. The grain halls were emptied to make room for more dancers and a stage was constructed to hold them. Musicians were hired to urge the dancers on. The dancing grew more and more frenetic, with the afflicted townspeople going at it day and night until, as the village authorities had predicted, the plague ran its crazed course and at last the flailing citizens stopped. But not, however, before dozens had died. Died of dancing, yes, but really of the social contagion that had transmitted the dancing from person to person.
Caring Clinicians
As has already been discussed, the rates of depression are climbing despite the fact that we supposedly have superior medications such as SSRIs to treat the syndrome. More and more people are getting sick. And as we have seen, sickness is often a social act – almost always contagious. Could the high rates of depression be due to the nocebo effect? And if this is the case, do we not have the answer, a way to stem the tide? A hand held forth? A saline solution administered by a doctor who cares? It’s possible that these may very well turn out to be the best cure of all.
Studies of the placebo effect by Ted Kaptchuk, a Harvard University researcher, definitively show that the more care you lavish on a person, the more symptomatic relief that person will get. One of Kaptchuk’s studies of patients with irritable bowel syndrome examined the effects of sham acupuncture. The catch here is that both groups of patients received the sham version of the acupuncture. The difference is that in one group the sham acupuncture was administered by a clinician who was cold and curt, whereas in the other group the s
ham acupuncture was administered by a clinician who was warm, who took the time to sit with the patient before beginning the ‘treatment’. The caring clinician was instructed to have a ‘warm friendly manner’, to sympathise with how difficult the condition must be for the patient and to stare thoughtfully into space for about twenty seconds. The curt clinician, by contrast, was instructed to say as little as possible to the patient during the ‘procedure’. The results? The patients who received treatment from the caring clinician had a huge decrease in pain and in irritable bowel symptoms in the weeks that followed, while the patients who had been with the curt clinician got far fewer benefits. Placebos require that we be kind, in other words, and they prove that kindness and compassion have potent biological consequences.
Medicine, however, may not be at a place where it can embrace these findings. That’s true especially of psychiatry, a profession that has long fought for the status of a science. It’s almost inconceivable that it would willingly backtrack into something as soft and fuzzy and even, yes, schmaltzy as caring. What about the PETs, the fMRIs, the studies suggesting the genetic underpinnings of psychiatric syndromes like schizophrenia and bipolar depression? But this is a false dichotomy. Science need not be tossed out the window in order for psychiatry to embrace the placebo. After all, the placebo is a biological phenomenon worthy of scientific study. Furthermore, even with successful placebos, we still need medicine. The placebo is not a cure-all; it doesn’t work on dementia, and it’s hard to imagine it working for the hallucinations and delusions of psychosis.
The Drugs That Changed Our Minds Page 24
