The Placebo Effect:

It’s not just a little white pill

The typical scientific definition of a placebo is, “The placebo effect is the measurable, observable or felt improvement in health or behavior not attributable to a medication or invasive treatment that has been administered.” – The Skeptics’ Dictionary (Skepdic.com).  The reason that the placebo effect is scientifically measurable is because the gold standard of any research on human beings includes a placebo control group, which is given a sham treatment or pill identical to the pill/procedure being tested but without the active ingredient or actual procedure.  The difference between the placebo group improvement and the actual procedure/drug being tested can then be measured.  This is the description of the placebo effect from the research point of view when a placebo is compared to an actual therapeutic procedure. There are a number of excellent articles on the placebo effect at Sciencebasedmedicine.org.

However, the placebo effect takes place whether or not you are comparing it to or measuring it against another pill, potion or procedure.  From the patients’ point of view, the placebo effect is a constellation of patient generated responses to the stimulus of a motivational story and a possibly therapeutic procedure.  The more dramatic the story and the more invasive the procedure, the greater the potential placebo effect that is produced. There is even a placebo continuum of sorts: sham surgery has a greater effect than a placebo injection; injections have more of an effect than placebo pills; brand name placebo pills have a greater effect than blank white placebo pills and taking placebos four times a day has a greater effect than taking placebos two times a day, etc.

Almost any procedure can have a beneficial effect if it is part of a “therapeutic” story.  What’s going on is a self-fulfilling prophecy: the healer is telling you that this procedure will make you well and you very much want to be well, so your body ralleys, physically and psychologically, to that end and a placebo improvement occurs.

The placebo pills, potions and procedures do not actually affect the intended illness and the particulars of the various placebo procedures are incidental to any improvement.  Test subjects given sham alcohol will demonstrate the effects of being drunk; asthmatics given water in their inhalers will show improvement in their asthma symptoms and subjects who are not lactose intolerant and who are told that they are will produce symptoms of lactose intolerance.

All medical procedures produce a patient generated placebo effect.  Science based medicine, complementary, alternative, integrative, folk medicine, ridiculous snake oil remedies, etc, all produce a placebo effect.  Surgery, stitches, acupuncture, aromas, magically energized water and sugar, alcohol, a cold shower, a slap in the face, cranial massage, rearranging invisible bio-fields, etc, will all produce a placebo effect if the “healer” tells the patient that the placebo will be curative.  Even harmful procedures, like swallowing a long, thin cotton sheet and gagging as you pull it out, bloodletting, sticking pins in your skin or frequent enemas will produce a beneficial placebo effect if it is tied to a therapeutic story that gives the patient hope for relief of their symptoms.

So, how does the patient generate this placebo effect?   Here are the elements of the constellation of events that produces the patient generated placebo process:

1. Being sick, injured, miserable and in pain causes our natural skepticism to be replaced by suggestibility and hope as we seek any method to relieve our illness or injury. We quickly become willing to abandon the Germ Theory of Disease for invisible energy, magical vibrations and other “forces”.
2. We listen to the anecdotal testimony of others who were “cured” by some interesting potion, procedure or exotic folk medicine from another country. Personal success stories are colorful, emotional and we tend to trust the storyteller.
3. The process of treatment behavioral conditioning from childhood tells us that if we go to a healer, take a pill and/or subject ourselves to a healing procedure that we will get better. This is a, “If it worked before, it will work again”, type assumption.
4. Many illnesses and injuries heal naturally but we make a false association between the potion/procedure and our improvement. In a classical Post Hoc Ergo Propter Hoc thinking situation, we imagine that just because our improvement came after the folk remedy, that the improvement happened because of the folk remedy.
5. The drama effect: the procedure or ritual may be painful, risky and spectacular: surgery, bloodletting and stitches are very dramatic. So is acupuncture, moxibustion, enemas, induced gagging and vomiting.
6. The physical insult/rally effect: if the procedure includes a physical insult like induced vomiting/gagging, purgatives, bloodletting, needles, surgery, stitches, etc, then the body normally is stimulated to heal itself and overcome the insult.
7. The distraction effect: the greater the bodily insult, the more potential there is to distract the patient from their pain and condition. For example, induced vomiting and gagging will temporarily distract you from a headache.
8. Once our condition improves, even temporarily, we fall prey to confirmation bias, looking for supporting examples and discounting scientific evidence contrary to our personal experience (“…but it works for me!”). This self-fulfilling prophecy makes us habitually prone to finding what we want to find.
9. The confessional effect: speaking to a “healer” for 60 – 90 minutes who genuinely accepts you and all your bodily ills and is so concerned about you returning to good health feels wonderful.
10. Actual placebo improvement: the above process generates some improvement, not because of the particular procedure, potion or pill but because of the effects that this thinking and feeling process has on our bodies: adrenalin release, endorphins, stress reduction, memories of being taken care of by Mom, etc.

So, the next and obvious question, harped on ad infinitum by non-science based medicine promoters is, “What’s the harm?”  Well, if ALL medical procedures produce a placebo benefit, wouldn’t it be better to use science based medicine that subtracts the patient generated placebo effect and actually produces additional patient improvement?   Charging patients for their own patient generated placebo effect is harmful.   Claiming that patient generated placebo effects are produced by invisible and magical forces is untruthful and harmful.  Wasting patients’ time, energy, money and delaying and distracting them from obtaining often critical, science based medical care (as in the unfortunate case of Steve Jobs) is very harmful.  That’s the harm.

By Victor Dominocielo, 4/12/14

Victor Dominocielo, M.A., a California-credentialed teacher for 36 years, is the human biology and health teacher at a local middle school. He earned his Master of Arts degree in education from UCSB. The opinions expressed are his own.