“My husband thinks I feel better when I see you because it's a placebo.”
I paused and thought to myself.
The remark from my patient wasn’t phrased as a question. But…. in a way it was
So, in turn, I asked one back…. “And what do you think?”
This patient had seen several PTs for persistent pain before coming to me. After years of seeking treatment, she was surprised to finally feel some improvement. She (and apparently her husband) wondered why...... why now?
I tell you this story because the placebo effect is habitually misunderstood. Not just by the general population but also by those in the medical field, including evidence-based medicine practitioners.
In this blog post, I aim to debunk some common myths and misconceptions about the placebo effect and shed light on what can be a contentious topic.
Myth 1: All placebos are the same
Although there are threads of similarity, research placebo and clinical placebo are not the same. Using the same term but meaning different things has led to overall confusion about the phenomena we call the placebo effect.
Research placebos are used in controlled studies to assess the effectiveness of new treatments, while clinical placebos are used in medical practice to enhance therapeutic outcomes, whether the clinicians or patients are aware.
Most people envision sugar pills when they hear the term placebo when in fact the placebo effect can occur because of multiple contextual factors.
For my persistent pain patient, it could have been a difference in the therapeutic interaction. Perhaps my clinic space made her feel safe. Maybe she believed the explanations I gave her. She might have expected a positive experience based on what her friend described.
maybe it felt like this
The placebo effect is a complex phenomenon in which a person experiences a positive therapeutic outcome from a treatment that is thought to have no active medical ingredients. As you can imagine this can occur in both an experiment but also in many aspects of life.
So why do we so often refer to it as “just placebo”?
Myth 2: Placebos are synonymous with fake or ineffective treatments
In clinical trials, placebos are described as inert substances or as sham (i.e., fake) treatments. These descriptors can be misleading and has led to a negative cultural perception of placebos and their effect.
Placebo effects should not be equated simply with treatments lacking efficacy.
While we are biased to think that within a randomized control study, we are observing the outcome of a certain intervention – we are concomitantly observing the performance of a placebo.
How ironic that the direct translation of placebo from Latin is “to please” and yet there are many negative undertones.
And since much of the confusion around the placebo effect derives from its name, is there a better phrase? Turns out there are several
Myth 3: It’s All in Your Head
Many believe the placebo effect is purely a psychological phenomenon.
As much as we’d like to separate mind and body we can’t. They are always interacting.
The placebo effect has physiological effects on the body, impacting various systems such as the endocrine, immune, and autonomic nervous systems. Studies have shown positive effects on gastrointestinal, cardiovascular, and pulmonary functions.
Perhaps this is what we see with laughter as medicine
Myth 4: Placebos can't help serious medical conditions
Even though the placebo effect is frequently connected to pain treatment, studies have demonstrated a variety of therapeutic advantages. Placebo treatments can be used to relieve suffering in Parkinson's disease, insomnia, and cancer-related fatigue.
Critics of the placebo effect argue that placebo interventions do not cure diseases and while this may be true, but relief of suffering holds much value.
Myth 5: The placebo effect is always harmless
While the placebo effect can be beneficial, there are instances where it may lead to negative repercussions, such as delaying proper medical care, masking severe symptoms, or overusing ineffective treatments.
and the quacks are out there... beware
Not everyone will react to a placebo the same way. One man’s placebo could be another’s nocebo. For example, some folks like needles, others hate them. This discrepancy exists for many interventions largely based on individual expectations. As they say, you can't please everyone.
Myth 6: Placebo responders are easily fooled
Another common myth about the placebo effect is that it only works on people who are gullible or impressionable.
The placebo effect can work on anyone, regardless of their level of skepticism or intelligence. Genetic and individual differences, as well as past experiences, beliefs, and preferences, can influence placebo responses.
Research looking at those who are more responsive describe the "placebome.” The placebome refers to a group of genetic variations within an individual that may influence their response to placebos.
Myth 7: Placebos are deceptive
Some individuals perceive the placebo effect as a type of deception. Placebo use has potential ethical concerns but not all placebos are deceptive.
Some of the most interesting recent research on the placebo effect is focused on what are known as open-label placebos.
An open label placebo is the administration of a placebo treatment where the subject is informed that they are receiving a placebo.
Several of these studies have shown that even when patients are aware they are receiving a placebo the placebo intervention can produce a positive effect.
Studies on open-label placebos have shown positive results for symptoms in patients with irritable bowel syndrome (IBS). (2010 by Kaptchuk et al), chronic low back pain (2016 by Charles et al, cancer-related fatigue and episodic migraine)
Administering placebos ethically with the patient's knowledge and consent can be beneficial. One of our biggest hurdles in conceptualizing placebo is agreeing on what we deem effective and beneficial.
Myth 8: A placebo response indicates treatment ineffectiveness
A placebo response doesn't always mean a treatment is ineffective. It may indicate the presence of non-pharmacological mechanisms. Factors like empathy, warmth, and confidence in a clinician can influence outcomes.
Additionally, it might not even indicate a placebo effect. Sometimes people just get better with time – this is termed the “natural course of disease” or “spontaneous improvement.”
Alternatively mislabeling of the “placebo effect” occurs with a phenomenon known as– regression to the mean. Regression to the mean is a statistical phenomenon and fancy way of describing how things (e.g., symptoms) often even out or improve over time.
Summary
The placebo effect is a fascinating phenomenon with extensive and on-going scientific research. Despite this there are still plenty of untruths and misunderstandings about the placebo effect. Likewise, people on both sides of the continuum who feel strongly about the potential benefits and hazards are unwilling to appreciate the gray.
Our use of the term placebo effect in medical research has led us to assume when this happens, it is a failure. When in fact to not employ factors that produce a positive therapeutic outcome would be a failure.
Leveraging the power of the placebo effect does not replace or negate the mechanisms of a therapeutic intervention. These effects occur despite our intentions or awareness.
The question is not do we or don’t we use the placebo effect clinically but HOW.
Understanding the placebo effect and its potential contributions can help us provide better care to our patients.
Photo credits: Courtney Cook, James Lee, Milad Fakmun, Luis Melendez and Zlafaky on Unsplash