The vespers for the dead began with the phrase, ‘Placebo domino in regione vivorum’ (I shall please the Lord in the land of the living). In the 12th century, these vespers were commonly referred to as placebos, a popular term of derision denoting their incomprehensible nature. By the 14th century, the term had become secular, suggesting a flatterer or sycophant – a meaning probably derived from the deprecation of professional mourners, who were paid to sing placebos. So in the middle ages, the placebo was applied to help the aggrieved cope with their loss. When the word entered medical terminology, the negative connotation stuck. A placebo was defined as a medicine given to please patients rather than benefit them.
After a while, placebos became associated with charlatanism and the exploitation of vulnerable people for financial gain. Burlesque and counterfeit; pills contained nothing more than dough, sugar and coloured water; their effectiveness was related entirely to the charisma of the showman.
In contemporary medical culture, placebos are the supposedly inactive ‘blanks’ in randomised controlled trials of drug treatment, but the effect of the placebo can be so strong that it may be necessary to study hundreds of patients to demonstrate statistical significance of the ‘active’ treatment. In some IBS trials, sixty per cent of patients with functional abdominal pain responded to placebo, diarrhoea was less responsive – nearer 40%, but even constipation improved in 30% of patients on placebo. Bearing in mind that active drug treatments only tend to achieve 60% efficacy at best, this suggests that the so-called ‘placebo effect’ is not only responsible for the efficacy of most complementary therapies, but also the major component of any pharmacological treatment for IBS. This calls into question the value of the cocktail of quite toxic drugs that are consumed by so many people with IBS?
So what is the placebo effect about?
The placebo effect emphasizes the power of persuasion and expectation. Like religion, politics, advertising, medical treatments often appeal to our intuition rather than our logic. Brexit was a triumph of hope over reason. Our feelings and behaviour are so influenced by trust and belief. Good doctors are good salesmen; they market themselves as custodians of a system based on evidence. They are metaphorical parents, imparting reassurance and confidence.
The counterfeit aspect of healing by placebo can be so convincing that doubling the ‘dose’ of placebo increases its efficacy and people may suffer side effects. It may even override any physiological action of the drug, as in the reports of laudanum being prescribed as a purgative and syrup of Ipecac as an anti-emetic. During the fibre revolution (Bran for all) of the nineteen eighties, coarse wheat bran captured the public imagination not only because people were told it would regulate their bowels, but also because it resonated with contemporary ideas of natural living and moral fibre, but when Dr Peter Whorwell demonstrated that many people actually had more bloating and pain on bran, they turned against it overnight. Currently, the strap-line ‘taking the good bugs to get rid of the bad’ is a major component of the success of probiotics. The knowledge that a treatment has some biological action gives the treatment ‘credibility’. The doctor can prescribe it with conviction and the patient take it with confidence.
Both the doctor who prescribes antispasmodics and the healer who administers homeopathic remedies believe in the effectiveness of their remedy. In each case, their patients often feel better because they trust their therapist’s judgement and adopt their belief.
But the placebo effect is not just the psychological triumph of persuasion over reason. The suggestion implicit in placebo therapy has been shown to have multiple effects on the brain, which include the suppression of the hypothalamo-pituitary-adrenal (HPA) axis and the amygdala, secretion of endogenous opiates and the release of dopamine.
How to enhance the placebo effect.
The art of medicine is the ability to enhance the placebo effect. So instead of trying to restrict the prescription of otherwise useful remedies through the artifice of randomised controlled clinical trials, medical institutions might do better to harness the therapeutic power of the placebo effect to the pharmacological properties of the drugs. The power of the idea is as important as biological efficacy. The aim of healing is to counter the helplessness induced by illness by the confidence fostered by belief.
The patient’s expectation can be conditioned by the way a tablet is marketed. If the treatment has a brand name the patient can recognize, it works better. Packaging enhances placebo effect. Expensive ads make people feel better on a certain treatment. Injections work better than tablets for some things. Colour also has an effect. Pink and red are uppers – good for depression. Even the setting, the arrangement of the room can make a difference. People recover faster from surgery if their room looks out on trees. Alternative or complementary therapies are more effective placebos than tablets because they emphasise the context and ritual.
A treatment that recruits the patient’s collaboration can sustain the belief. I often advise people with IBS diarrhea to take a resin called cholestyramine (Questran), which binds unabsorbed bile acids which irritate the colon. I tell them to take it half an hour before meals and titrate it with both the size of the meal and symptom response. It can be very effective, but is its efficacy is based as much on my belief in the treatment and their engagement with the therapeutic process? Similarly, a low FODMAP diet can be very useful for exacerbations of bloating and/or diarrhoea, but the effect only lasts if patients understand the principles of treatment and can adapt their diet to suit them.
In contrast, a drug that has an appropriate biological action but is administered without endorsement or instruction can be disappointing. It has been suggested that doctors ‘should treat as many patients with the new drugs while they still have the power to heal’. The first clinical trials of any new drug are often the best.
It could be said that treatments that capture the imagination, instil confidence and security, and suppress anxiety without a convincing biological action, are essentially manipulative. Doctors who believe the evidence, will convey this to their patients with beneficial results. Conversely, the blatant deception of a placebo can be counterproductive, since, if discovered, patients experience a devastating loss of trust, negating any future chance of healing. If, however, people are told a treatment is a placebo, it may still be better than no treatment at all.
It’s not what you do but the way that you do it.
‘Healing’ depends on the ‘quality’ of the therapeutic relationship. Doctors who appear calm and confident, exude an air of conviction and authority, pay careful attention to the patient’s history and offer an unhurried explanation of the treatment, are likely to elicit better responses than exasperated doctors who have little time to care. Their authority and credibility are emphasized by their manner and demeanour, how they dress, the diplomas on the wall, as well as the setting, and the décor. Engaging with their patients, looking them in the eye, not at the computer screen, taking time to understand them, are essential components of the art of healing.
When, I was a medical student, the processional ward round of the dark suited consultant and his white coated attendants, the theatrical conclave in the middle of the ward and the complex and bewildering scientific language created a therapeutic sense of awe and authority. The careful and respectful clinical examination did not only elicit the abnormal sounds, reflexes, lumps and tenderness; the ‘laying on of hands’ broke down reserve and established a connection. Such theatrical healing practices have been implicit in the art of medicine since the earliest times; they recruit the patient’s confidence and expectation.
IBS is often an expression of the individual, their life style and life history. Hope, faith, expectation and belief are the essential elements of healing. Only a treatment that the patient identifies with can promote their faith and confidence and restore self actuation and well being. This will vary between patients depending on life style and life history. Randomised controlled therapeutic trials treat everybody the same and would thus tend to obscure and undermine the essential individual component of healing. Is that perhaps why there are so few proven remedies for IBS?
Read NW (2005) Sick and Tired: Healing the illnesses doctors cannot cure. London, Weidenfield and Nicholson.
Patel SM, Stason WB, Legedza A, Ock SM, Kaptchuk TJ, Conboy L, Canenguez K, Park JK, Kelly E, Jacobson E, Kerr CE, Lembo AJ. (2005). The placebo effect in irritable bowel syndrome trials: a meta-analysis. Neurogastroenterol Motil. 17: 332-40.