Living on Planet Placebo

placebo effect

My most unethical psychological experiment to date involved treating my accountant friend Greg to what is now considered to be an “alcopop.” With his back turned, I dashed some into a tot glass and palmed the rest to my not-so-glamorous assistant. I announced that this drink was aptly called a “Silver Bullet!” I went on to claim that the barman had made a passing remark about it being by far the strongest concoction in the house. As an aside, I kindly warned him that soon he might not able to walk and that perhaps it was a good idea to sip it slowly. The experiment was too successful and backfired terribly, as I was left to negotiate with a now slurring and inebriated birthday boy. Getting him home early was even harder.

The question is: Did my suggestion change the chemicals in Greg’s brain?

Some online self-help techniques are quite amazing, others not so much — but  they are all ingeniously marketed. The self-help promotion is almost Oprah-like, filling you with sheer excitement in anticipation of the confident, smooth talking, all remembering, speed reading, money attracting and six-pack having new you. Quickly, buy now! This special and unique offer for you to change your life expires tomorrow. If you delay, you will not have a mansion with a fountain. You will not be able to drive your sports car around the fountain. You will not retire to the Caribbean. Click here now or continue to live a life of mediocrity, regret and shame… Are you sure you want to leave this page?

Look, it’s not psychology’s prettiest moment and you should be extremely skeptical  You may find yourself asking:

“Isn’t this just a placebo? If I think it works, then it will.

There some incredible things out there – don’t get me wrong. However even for these the question will be partly true — not entirely true.

A fairer question is:

“Okay, how many of these things are likely to be placebos?”

Religion, allopathic medicine and management consulting have all been alleged to be placebos. Some say that as soon as something stops being a placebo, it’s becomes Western Medicine. This couldn’t be further away from the truth. Religion and allopathic have been given a pass on this one, although personally, I’m not sure why.

What is a placebo?

[showmyads]Pharmaceutical companies conduct clinical trials to acquire permission to sell their stuff. To do this, they need to show that their stuff works. To be considered “working” it must be shown to get more improvement than a placebo does. A placebo in a medical setting, is an injection of saline solution (salt water) or a sugar pill of a specific color — neither of which has any pharmacological effect. Randomly chosen test subjects get the real medicine, and the rest get the sugar pill — blue if the drug is made to calm you down, and Red should the real medicine involve getting you to actively do something.

The researchers themselves don’t know who is who until the end, and this approach is called a randomized controlled double blind testing (Leber, 2000). This form of group testing is undertaken at great expense and effort to control for the said placebo effect. The placebo effect refers to the phenomenon where improvement occurs even though no real treatment is received – and it is freakishly weird.

If you think it will happen, then quite likely under the right circumstances it will happen.  The Law of Attraction is also very placebo-esque. It claims that “like attracts like” and that a focus on positive or negative thoughts can bring about positive or negative results.

If the Law of Attraction is a real thing and maybe it is, it would mean the whole world is a placebo.

Similarly, if you’ve endured the Matrix trilogy, be assured that both the pills were placebos.

The placebo effect remains one of the most confusing idea in medical science (Brooks, 2009). The more we learn, the more confused we become.

Simple but inadequate explanations

So far, we have three very weak explanations of the phenomenon. You may have heard of them already. The first is that neither the treatment nor the placebo effect is real – the illness goes away on its own accord. Tempting, yet depressing. To put this to the test we need only include a “third wing” to the study – those who don’t receive anything.

People like the second explanation. It’s a popular one. It holds that the placebo effect comes as a result of the quality of care one receives, personal attention and love. The very worst homeopath and the very best clergy in the world believe this to be the case.

The third explanation, is similar to the second, but placed squarely at the feet of subjective delusion. It holds that psychological and physiological ailments are one in the same. Convincing the mind is the same as convincing chemicals within the body (Vogelson, 2002). This feels right. Psychologists love this. Psychiatrists adore this! But upon review of the data, none of these explanations seem to crack the nut.

Placebo? Really? Okay then.

The best of the placebo comes from the faith you have in your doctor or therapist. Just to show you I’m not biased, I’ll throw in a homeopath, a priest and the guy off late night television who is trying to sell you something for your kitchen to make you feel better about your life. Throw in designer labels, multivitamins and that cliché someone inevitably says to you when you’re incredibly upset, you know the one, something about time’s healing properties… There is something about the belief that you will feel better, be better, improve, change your life which causes the healing. We just don’t know what it is.

It might have something to with a white lab coat. That’s probably the best we’ve got so far. When sugar pills are administered with a soothing voice and good news for the future, the sugar pills will reduce fear, anxiety and pain (Goldacre, 2009.) Have you ever heard your Doctor say, “I’m going to give this medicine to help with…” It’s like a chant. It’s called “the Doctor’s incantation.” Whether the medicine works or not, the incantation helps.

According to the 2001Journal of the American Pharmaceutical Association, Pharmacists are strongly obliged to play along with a placebo prescription. They are encouraged to offer you a canned response like, “Generally a larger a dose is used for most patients, but your Doctor believes you will benefit from this dose.” It’s easy to believe your doctor, and so it’s hard to believe that this happens in every day practice. Moreover, this cunning sham is largely considered to be wholly ethical. I kid you not.

A study by the Oregon Health Sciences University found 35%-45% of drug prescriptions to be nothing more than placebos (Helm, 1985). A later study of Israeli doctors had 2 out of 3 prescribing placebos. Over half the placebo pushers do so once a month or more. Before you fall off your chair, know that in 94% of the doctors rely on them to be successful treatments (Nitzan and Lichtenberg, 2004). And yes, it gets weirder. Scroll down.

What isn’t Placebo?

Can you tell the difference between a placebo and a real treatment? If you can, your mother was right about you…you truly are very special because not even medical science is able to do what you can. When 19 clinical trials of antidepressants were reviewed, 75% of the effect was put down to the placebo effect. The remaining 25% was attributed to factors other than the actual action of the drug (Kirsch & Sapirstein, 1998). Remain seated. The Boston Globe investigated Prozac in a great 1999 expose. They found only the placebo effect in 6 out of 10 clinical trials (Moore, 1999). Between 1979 and 1999, in 52% of 96 antidepressant trials, the action of the drug could not be distinguished from the placebo (Burne, 2002). Having considered these reports, it begs the question: Why exactly are we pouring billions of dollars into Big Pharma each year?

The placebo effect is not something one can directly observe: It’s a statistical measure, and as such it’s difficult to truly understand what it’s doing without a basic background in statistics. Suffice to say that it is NOT possible to statistically piece apart the placebo from the actual drug.

Does our niceness cause placebo?

Hróbjartsson and Gøtzsche (2001) looked through literally hundreds upon hundreds of clinical trials. They were not convinced that the placebo effect was very strong at all. Their big finding, which struck a chord with the academic community, was that there only seemed to be a solid placebo effect in studies in which the patient’s subjective evaluation was at play — that is, in pain relief studies. As patients are typically very sweet and nice to their white-coated doctors, this is reasonable; “placebo” literally means I shall please.

This finding was soon refuted. In a study by the University of Michigan, PET scans were used to monitor the endorphin levels in the hypothalamus of the test subjects. Even though the patients in this study were given to reason to report less pain, the PET scan showed the pain subsiding, they didn’t (Benedetti, Mayberg, Wager, Stohler & Zubieta, 2005). It was demonstrated that the placebo effect wasn’t necessarily associated with an overwhelming desire to please.

The weird and wonderful Placebo

Do you have a good idea about what the placebo effect is and how it works? Well, it has something to do with soothing tones, convincing websites, and the confidence of the guy selling you something for your kitchen. Trying to form a coherent idea about the placebo effect is like playing the game ‘Snakes and Ladders.’

Patients who know they’re on a placebo will not show any improvement. That’s fair. Studies have also shown that perceived group assignment has the same effect as actual group  assignment (this is the reason researchers are required to do a “double blind” test, and they only find out who is who when the results are in).

Now here’s the kicker. Repeated studies show that anti-depressants have no effect unless you know you’re taking them. So if you’re miserable but don’t know you have anti-depressants in your system, you will still show all the signs and symptoms of your depression. No change at all (Collins and Pinch, 2005; Brody, 2002).

Shocked? How about this: It has also been shown that when a patient who is in pain is given Morphine, the pain goes away – as you’ll expect. However, when the Morphine is replaced without the knowledge of the patient, with a salt water solution, low and beyond, the pain does not return. By now, you should be quite familiar with what is at play here.

Keep in mind that the patient still thinks he’s on the Morphine, and so the ‘expectation’ pain blocker is still working. Now let’s secretly swap the saline solution for Naloxone, a very weak chemical which blocks the action of Morphine and does nothing to saline (remember there is no Morphine in the patients system for Naloxone to go to work on), and low and behold, the patient is again in pain (Brooks, 2009).

So here we have salt water working like Morphine and another chemical stopping salt water from working as a heavy duty painkiller. Here you are left with a choice: you either believe that salt water is amazing or that the placebo has a real biochemical basis. Do you recall that reference to “snakes and Ladders?” Well, welcome back to square number one. Get comfortable.

Just as I did with my friend Greg, Benedetti (2009) boldly stepped into slightly unethical grounds. Enter the reverse of the placebo – the “nocebo” effect. Benedetti took a harmless drug and suggested to the patient that in order to treat them, it’s going to first make them feel worse. (Benedetti had to make do with paid volunteered in order to skirt the ethics committee.) Essentially, Benedetti was reversing the Naloxone study. The nocebo effect turned anxiety into real pain. By taking repeated blood samples while administering the neurochemical blocker Proglumide, the nocebo effect was stopped!

Limits to placebo

We know this, the placebo effect, while powerful cannot achieve miracles. Homeopaths and televangelists who trade on these so called “molecules of hope” should pay attention to the research. While a placebo is cheaper than most drugs used to treat an irritable bowel, and is just as effective, the effect has hard limits (Brooks, 2009b; Kaptchuk, 2008). Placebo cannot cure diseases, attack HIV or bring organs back to life. This warning specifically applies to cases where the condition cannot be treated by a placebo, but the symptoms can.

Answering the big question

I’d like to think Subliminal Today is well respected for being credible and honest – part of this is facing up to these big questions. There is a wall of scientific research to say that some self-help approaches do work. Their effects are shown on MRI and PET scans and through behavioural change. Still, placebo effects cannot be pulled apart from the real effect of the treatment — be it an antidepressant or a subliminal programme. Suffice to say that the bar of evidence should not be different when it comes to self-help approaches. For a self-help approach to be worthwhile, it must be shown to outperform the placebo effect. Self-help is not for everyone. There are some studies which show subliminal programming to be only placebo (Greenwald, Spangenberg, Pratkanis, Eskenazi, 1991), but there are also many which show subliminals to work beyond placebo. Just like chemical treatments, not only can we show them working, the scans also show how they work. Both antidepressant research and subliminal research have confirmed a treatment-placebo difference.

The truth is that white coats, pills and injections, soothing tones and clipboard are no better than big flashy websites, cool sales speak and lots of “scientific evidence” with some liberally scattered quotes from people like you, who say it works too. The placebo effect in subliminal programming is extremely strong and is played up as much as possible. Just like Western medicine, this is considered to be wholly ethical.

Subliminal self-help is far more effective than it ought to be because those who use it are open to change, desire self-improvement and are very much committed to using the programming. They expect it to work, so it will.

As with any psychological intervention, if there is no positive expectation, there is no effect.

Strangely, unconscious treatments differ from the chemical counterparts because of how they work – you need to be unaware of the messages in order for them to work. Ironically, this is how they are proven. Test subjects are not “let in” on the true nature of the experiment.

So where does this leave us? No doubt, the placebo is a big part of the package. There is no way to deny it. As long as you’re happy that you’re following a treatment properly backed up by research, which has been shown to work beyond the placebo effect, then why not get excited about it and throw yourself into it? Use the placebo effect to your own advantage, and let it benefit you as much as you want it to.

(My dear friend Greg however, is yet to forgive me. He is still my accountant.)

If you’d like your questions about subliminal self-help answered – visit Subliminal Today’s FAQ page or join me on Facebook.

References:

Benedetti, B., Mayberg, H.S.,Wager, T.D, Stohler, C.S., and Zubieta, J. (2005) Neurobiological Mechanisms of the Placebo EffectThe Journal of Neuroscience, 25(45), 10390-10402 retrived from http://www.jneurosci.org/content/25/45/10390.full.pdf+html

Benedetti, F. (2009). Placebo Effects: understanding the mechanisms in health and disease, Oxford University Press.

Brody, H. (2002), The Placebo Effect: Implications for the Study and Practice of Complementary and Alternative Medicine’, The Role of Complementary & Alternative Medicine: accommodating pluralism, ed. Callahan, D., Georgetown University Press.

Brooks, M. (2009a). 13 Things That Don’t Make Sense: The Most Intriguing Scientific Mysteries of Our Time.  New York: Random House.

Brooks, M. (2009b) Homeopathy: Sometimes a dose of nothing can do you a power of good. Guardian. 6th February retrieved from http://www.guardian.co.uk/science/blog/2009/feb/06/homeopathy-homeopathic-nhs-placebo-effect

Burne, J. (2002, June 20). Make-believe medicine. The Guardian. Retrieved February 1, 2003, from http://www. guardian.co.uk/Archive/Article/0,4273,4444420,00.html.

Collins, H and Pinch, T (2005), Dr Golem: How to Think About Medicine, University of Chicago Press.

Goldacre, B (2009), Bad Science, HarperCollinsPublishers.

Greenwald, A.G., Spangenberg, E. R., Pratkanis, A. R., &., Eskenazi, J.(1991). Double-Blind Tests of Subliminal Self-Help Audio Tapes. American Psychological Society, 2(2), 119-122.

Helm A. Truth tellingplacebos, and deceptionethical and legal issues in practiceAviat Space Environ Med1985 Jan;56(1), 69-72.

Hróbjartsson and Gøtzsche (2001) Is the Placebo Powerless? — An Analysis of Clinical Trials Comparing Placebo with No Treatment New England Journal of Medicine, 1594-160 retrieved from http://www.nejm.org/doi/full/10.1056/NEJM200105243442106

Kaptchuk et al. (2008) Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. British Medical Journal, 336-999 retrieved from http://www.bmj.com/content/336/7651/999

Kirsch, I., & Sapirstein, G. (1998). Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medication. Prevention & Treatment, 1.

Leber, P. (2000). The use of placebo control groups in the assessment of psychiatric drugs: An historical context. Biological Psychiatry, 47, 699-706.

Moore, T. J. (1999, October 17). No prescription for happiness. Boston Globe, E01.

Nitzan, U, & Lichtenberg, P. (2004); ‘Questionnaire Survey on the Use of Placebo’, British Medical Journal, 329, 944-6

Volgenson, C.T. (2002, July). Searching for the Placebo Effect. Modern Drug Discovery. Retrieved from http://pubs.acs.org/subscribe/archive/mdd/v05/i07/pdf/702clinic.pdf

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