Constructing the Constructing the Placebo Effect in the Placebo Effect in the Placebo Wars: What is Placebo Wars: What is

the Way Ahead?the Way Ahead?  

Doug Foot (School of Life Sciences, UoW)Doug Foot (School of Life Sciences, UoW)Dr Damien Ridge (School of Life Dr Damien Ridge (School of Life

Sciences, UoW)Sciences, UoW)

Full paper currently in review : Doug Foot, Full paper currently in review : Doug Foot, Damien Ridge, Damien Ridge, Constructing the Placebo Effect in Constructing the Placebo Effect in

the Placebo Wars: What is the Way Ahead?the Placebo Wars: What is the Way Ahead?  

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Background Historical perspectiveHistorical perspective Psychological explanationsPsychological explanations Sociological & anthropological perspective - Meaning Sociological & anthropological perspective - Meaning making, placebo as ritualmaking, placebo as ritual

Psychotherapy – therapeutic relationshipPsychotherapy – therapeutic relationship CAM – ‘placebo’ as stigmaCAM – ‘placebo’ as stigma Rebranding placebo – contextual healing & meta-placeboRebranding placebo – contextual healing & meta-placebo Conclusions & the way aheadConclusions & the way ahead

In recent years, discourses about placebo have pursued a In recent years, discourses about placebo have pursued a number of key directions, and the current review paper number of key directions, and the current review paper explores these developments.explores these developments.

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What is a placebo?

……a placebo is any treatment (including drugs, surgery, a placebo is any treatment (including drugs, surgery, psychotherapy, and quack therapy) that is used for its psychotherapy, and quack therapy) that is used for its ameliorative effect on a symptom or disease but that ameliorative effect on a symptom or disease but that actually is ineffective or is not specifically effective for actually is ineffective or is not specifically effective for the condition being treated. The placebo effect then is the condition being treated. The placebo effect then is primarily the nonspecific or psychophysiological primarily the nonspecific or psychophysiological therapeutic effect produced by a placebo, but may be therapeutic effect produced by a placebo, but may be the effect of spontaneous improvement attributed to the the effect of spontaneous improvement attributed to the placebo. placebo. Shapiro & Shapiro, (1997, pg. 1)Shapiro & Shapiro, (1997, pg. 1)

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Historical perspective Motherby’s (1785) medical dictionary - first modern definition of the term; “a commonplace method or medicine”.

Foster’s (1893) ‘An Illustrated Encyclopedic Medicinal Dictionary’; “something that was administered for its effect on the patient’s imagination rather than because it is of medicinal value”

Beecher (1955) - essential to compare the efficacy of new medical interventions. Efficacious therapy = a positive effect greater than those of a replicated fake (placebo) treatment in a RCT.

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Historical perspective cont..

This RCT led definition contrasts to some past clinical practice where the placebo was historically considered a way of inspiring hope when there was not much else available to treat patients (Harrington 2002; Kaptchuk 1998; Moerman 2002a; Thompson et al 2009).

By the late 1990’s, Shapiro & Shapiro (1997) challenged the narrow medicalisation of placebo, arguing that any definition of the placebo should include the psychotherapies arguing that in reality it is impossible to distinguish between ‘inert’ and ‘active’ in treatments.

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Psychological explanations

In both biomedicine and psychology there have been two key theories - classical conditioning and expectancy theory

Pavlov - classical conditioning posited that placebo effect was an outcome of an automatic reflex ‘conditioned’ response.

Expectancy theory is premised on the expectation that a proposed course of treatment will facilitate physiological and emotional change.

Bandura (1997) suggested that ‘response’ expectancy is fundamental to all therapeutic responses, including the placebo.

Also possible that the anxiety alleviating effect of a therapeutic encounter may contribute to a placebo effect.

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Meaning-making Social ConstructSocial Construct Sociologists such as Price (1984) suggest that the placebo effect is ultimately a social construct, determined by how people make sense of their reality.

For anthropologists like Moerman (2002), the meaning response includes both physiological and psychological effects. He notes that his framework should not be equated with ‘non-specific’ effects, as many effects are in fact very specific.

Thompson et al. (2009) criticises Moerman for an over simplistic explanation for all things that cannot be attributed to the specific impact of the intervention, or the natural course of the illness & also for ‘talking up’ the patient’s conscious interpretations of their illness/recovery, as contrasted to their unconscious processes.

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Placebo as RitualPerformance efficacyPerformance efficacy For Tambiah (1990), CAM involves a significant amount of what anthropologists call ‘performance efficacy’. CAM and practices like psychotherapy involve the performance of rituals (e.g. creation of space and time) that may have an effect on clinical efficacy.

The idea of placebo as emerging from social ritual is controversial, but the attraction and power of ritual is well known in anthropology. According to Kaptchuk (2002: 817), CAM is ideal for creating placebo effects.   

With CAM, it is possible that the possibility for clinical change is supported by an idealized construction of metaphysical elements such as ‘qi’ in acupuncture or ‘vital force’ in homeopathy.

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The therapeutic relationship

With psychotherapy, studies suggest that it is the therapeutic relationship and other ‘nonspecific’ factors that contribute to much clinical effectiveness (Seligman 1995; Smith and Glass 1977; Smith et al 1980).

Lambert and Barley (2001) suggest that the quality of the psychotherapy relationship may account up to 30 percent of improvements in patients & another 15% is said to be due to patient expectancy.

However, difficult to know how much the practitioner, intervention and/or effect of the therapeutic relationship are responsible for clinical effectiveness (Cooper, 2010).

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Tainted by association? : Placebo

as stigma Throughout the first decade of the 21st Century CAM has frequently been dismissed as placebo (Thompson et al 2009: 118).

Most famously, the results of a meta-analysis of placebo-controlled trials of homoeopathy suggested that the sum benefits of homeopathy could be labeled a ‘placebo’ effect (Shang et al 2005)

Bootzin and Caspi (2002: 125) come to the provocative conclusion that if the effectiveness of CAM is due to the incidental elements (therapeutic relationship) then it may be unnecessary for practitioners to be trained in specific CAM techniques, but rather in how to best harness the placebo effect of a clinical intervention.

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Placebo as stigma cont… For Singh & Ernst (2008), the effects of CAM are largely dismissed as the therapeutic relationship enhancing the placebo effect.

As their discourse has hardened against CAM over time, we note that their writing seems to have differentially stigmatised CAM, rather than biomedicine even though they advocate the existence of a placebo effect in operation within both systems.

For these authors, there is a struggle to make sense of what is the most stigmatized; ‘placebo’ as both concept and practice, or CAM treatments with efficacy being at best due to the operation of placebo effects.

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Rebranding Placebo - Contextual healing

Contextual HealingContextual Healing Miller and Kaptchuk (2008) have devised the term ‘contextual healing’ as an alternative way of making sense of the placebo effect i.e. the sum total of all of the dynamics between patient and therapist that contributes to improved therapeutic outcomes.

Miller and Kaptchuk (2008) critique the language that is associated with the ‘placebo’ phenomenon. Placebo has often been defined by what it is not, with negative connotations of association by using terms such as ‘inert’, ‘inactive’ and ‘non-specific’.

They suggest that most placebos cannot be inert or inactive if paradoxically they produce a genuine effect.

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Rebranding Placebo - meta-placebo

Meta-placebo:Meta-placebo: Van Deventer (2008) seeks to embed placebo therapy as part of mainstream medical practice, especially for the chronically ill.

He suggests that fake or ‘meta-placebo’ treatments could be tested by setting up a double-blind experiment comparing outcomes of those receiving the divulged treatment or ‘meta-placebo’ with both a test group who in this case would be the placebo group and a do nothing group which is aware of their status as a control group.

Chiappedi (2009:99) goes one step further by suggesting that in addition to the two abovementioned controls, a 3rd control involving the administration of a potentially effective drug.

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ConclusionConclusion Clearly, there is no one agreement on what the placebo is nor what it is not.

Perhaps the only unifying thing about placebo is that it is potentially a component in contributing to positive change in all medical and CAM interventions, although many authors would disagree, even with this.

Along the lines suggested by Lewith (2010) we also believe that there is a case to thoroughly examine patient expectations behind the seeking of CAM therapies such as acupuncture, especially during a period of heightened skepticism within biomedical circles about the efficacy of CAM.

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The way ahead The way ahead Further qualitative investigation into patient experiences involved in the placebo arms of RCT trials may be a useful way forward in terms of understanding the placebo effect.

By using Kaptchuk et al’s (2008) idea of contextual healing as a launch, it should be possible to better explore people’s motivations around why, frequently in the absence of an evidence-base to support their clinical efficacy, people still continue to choose to engage in a diversity of therapeutic encounters.

As van Deventer (2008) suggests, ultimately maybe it doesn’t matter if a patient knows if a medicine is ‘real’ or not, providing both provider and consumer believe that it has some sort of healing effect.