The Placebo Effect: Contextual Healing

The Placebo Effect: Contextual Healing

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The real problem with placebos is the ethical considerations of their use. Is it ethical for a doctor to misinform or mislead a patient? The placebo effect is a well-known phenomenon, but also a controversial phenomenon. Can our mental abilities affect the chemistry in our body? Does the way we think, our habit of mind, have a real impact on our physical health? The answer is “YES”.

A survey of US physicians in 2008 shocked many people: over half of American doctors admit to using placebos in their treatment of patients. This and international studies tracking the common use of placebos in medicine is causing quite a stir. Why?

It’s certainly not due to lack of studies concerning the efficacy of placebos. They have a long-established history of use and effectiveness in medical history.

  • Patients have rid themselves of warts when doctors painted them purple and shrunk cancerous tumors with saline solutions.
  • Dr. Henry Beecher used sugar pills to relieve the pain of wounded soldier in WWII.
  • Leonard Cobb found that sham surgery cured angina pain just as well as the real procedure did in the 1970’s.
  • Patients who underwent surgery for pacemaker implants improved before the devices were even activated.
  • People undergoing dental surgery got just as much pain relief from a saline solution as those who received actual morphine.
  • Parkinson’s patients who received fake surgery instead of real implantation of human embryonic dopamine neurons experienced the same benefits as those who had the real surgery.
  • Skin incisions instead of arthroscopic surgery healed patients with knee osteoarthritis as well as the real deal.

Present-day technology is allowing researchers to begin to pinpoint the physiological bases of placebos: how expectation, thought, conditioning and other mental processes can affect changes in brain opiates, brain impulses and other bodily processes.

  • A neurologist at the University of Michigan discovered, with the use of fMRI scans, that a placebo pain injection initiated activity in an area of the brain called the nucleus accumbens (NAcc). This is the same area of the brain that controls our expectancy of reward.
  • Also at the University of Michigan, researchers used molecular imaging to measure the opiate activity in the brain. While inducing muscle pain, they gave volunteers a saline solution as a fake pain reliever.

The saline produced activity in those brain regions that inhibit pain and stress with the brain’s natural opiates, endorphins.

  • Neuroscientist Donald Price used fMRI technology to scan the brains of patients with irritable bowel syndrome. As they endured a painful procedure, the patients were given what they thought was a pain reliever. Not only did the placebo reduce pain, brain activity declined in five of the pain-sensing regions of the brain.

Research has even found what factors influence the effectiveness of placeboes. Fake surgery works better than injections; injections work better than fake pills; capsules are more effective than tablets; the bigger the pill the better; the more the better; the more expensive…etc.

The real problem with placebos is the ethical considerations of their use. Is it ethical for a doctor to misinform or mislead a patient?

Some doctors admit to prescribing treatments that have no proven efficacy but that is true of many commonly prescribed and popular drugs. Lipitor has only undergone 4 years of study; placebos work as well as many major antidepressant medications 35%- 52% of the time.

Other doctors believe that anything that helps a patient utilize their own power, whatever it may be, to aid in the healing process, just makes sense. This kind of thinking has led to a shift in the perception of placebo-use, how the focus of research could become how to initiate and develop the powers of the mind in healing instead of the focus on proving the basis of their physiological workings.

Researchers Franklin G. Miller, Ted J. Kaptchuk, Daniel E. Moerman and Wayne B. Jonas have proposed a re-conceptualization of the placebo effect. Miller and Kaptchuk believe the whole system should be referred to as “contextual healing.” Moerman and Jonas think of the placebo phenomenon as “the meaning response.”

What all of these researchers point out is the important fact that there is no way to isolate and study the placebo effect: it does not occur in a vacuum; it does not occur out of context. Placebos themselves are “inert;” they don’t cure anything. The many processes that do affect healing occur through the mind.

A doctor’s white coat or a stethoscope can trigger unconscious conditioning or beliefs about the efficacy of treatment. Media coverage can convince patients that a medication is good or bad. The more time a doctor spends with a patient; the more effective any treatment the physician prescribes will be. Telling a patient that a treatment “will work” results in more benefit than saying it “might help.”

Some researchers believe that acupuncture works so well with irritable bowel syndrome and lower back pain because of the increased attention, empathy, focus and time that an acupuncturist client receives versus what they get in a conventional doctor’s appointment. One of the things that is convincing about this theory is the fact that sham acupuncture works just as well as the real deal in many cases.

As one doctor explains, “Our health care system isn’t really set up to reimburse for empathy; it reimburses for widgets. So doling out something becomes sort of a modest gesture toward a mutual hope that the patient will get better.”(Berthold, Jessica 2009)

Neurologist Robert Burton says, “Even given our advanced state of treatments, medical knowledge, much of routine medical care—from treating backaches to the common cold—relies primarily upon reassurance and hope, not disease-specific treatments…we need to reconsider how to facilitate the placebo effect with minimal risk and cost, and without deception. “(Berthold, Jessica 2009)

Miller and Kaptchuk’s contextual healing is based on the premise that health occurs “spontaneously” when conditions are right. They refer to contextual healing as “that aspect that is produced, activated or enhanced by the context of the clinical encounter, as distinct from the specific efficacy of treatment interventions…”

They go on to explain some of the aspects that make up such a context. “Factors that may play a role in contextual healing include the environment of the clinical setting, cognitive and affective communications of clinicians, and the ritual of administering treatment. Attention to contextual healing signifies that there is more to medicine than diagnosing disease and administering proven effective treatments. This has long been recognized under the rubric of ‘the art of medicine.’”(Miller & Kaptchuk 2008)

Moerman and Jonas claim that “For human beings, meaning is everything that placebos are not, richly alive and powerful. However, we know little of this power, although all clinicians have experienced it.” These researchers emphasize that there is no way to avoid the placebo effect, even if one tries to avoid actually prescribing fake pills or treatments.   “One cannot… avoid meaning while engaging human beings.”

The researchers note that “eliciting the meaning response requires remarkably little effort (“You will be fine, Mr. Smith.”) So why doesn’t this happen all the time? And why can’t you do it yourself?”

Perhaps, they propose, only when some ritual is added (as in placebo treatments) or when some level of social support adds impetus to the patient’s inner abilities, do benefits occur.

Or, maybe, they muse, as we have clarified, routinized,and rationalized our medicine, thereby relying on the salicylatesand forgetting about the more meaningful birches, willows, andwintergreen from which they came—in essence, strippingaway Plato’s “charms”—we have impoverished the meaningof our medicine to a degree that it simply doesn’t work as wellas it might any more.” (Moerman & Jonas 2002)

Some scientists are suggesting the development of “meta-placebos” or “curabo treatments.” That is, helping people to understand that they can get help from the placebo effect, helping them to recognize the power of their own minds and insights, empowering or igniting them consciously might be a way to make use of the placebo effect in an ethical way.

One of the strongest arguments for “contextual healing” comes from a recent study of ADHD medications. When a placebo was used, children’s behavior improved. The surprise was that the change in symptoms seemed to have occurred not only because of the children’s expectation and because of “conditioning” about medicine but due to the expectations and beliefs of parents and teachers who believed that real medication was being administered.

Researcher Daniel A. Waschbusch says, “We speculate that the perception that a child is receiving ADHD medication may bring about a shift in attitude in a teacher or caregiver. They may have a more positive view of the child, which could create a better relationship. They may praise the child more, which may induce better behavior.”(Nauert, Rick 2009)

Matthew Budd came to see that 60% of the patients that visit doctors do so because of stress and emotionally-based physical symptoms. He developed an approach for improving health and well-being through improving interpersonal communications between doctors and patients, communication that addressed language, emotions, actions, behavior and the body.

He explains the role doctors, placebos and the mind play in healing.

“One of the things that most people aren’t aware of is that healing is a perfectly normal and natural phenomenon. When you cut your skin by accident or when a surgeon does it by intention, the surgeon may sew it up, but that isn’t healing the wound. The wound heals as an expression of a natural phenomenon. Healing is natural and normal. I think that occurs not only on a physical level, healing forces also restore balance and harmony. What many of us do is impede our own healing.

Healing is a birthright of the organism. I’m talking about the physical, emotional and relational restoration that is the relationship of intimacy; a contextual healing of harmony and trust in which a person feels at home in the world. Those things are impeded by certain barriers. An infection in a wound, the growth of bacteria, would be a barrier to physical healing. The barrier needs to be treated and removed before the healing will occur.

Once we leave the physical realm, the barriers that we need to remove are barriers of perception that generate negative mood states like anxiety, fear, anger, depression and negative connectional states like isolation, lack of relationship, anger, hostility, arrogance, so that we can experience our connection with other people, with nature, and with the whole of creation. 

So our healing possibilities lie in identifying and removing barriers at all these different levels rather than in doing anything. If we turn our attention to penetrating, experiencing, understanding, and seeing the delusional nature of these barriers and moving beyond them, then healing will begin to happen.” (Ingrasci, Raz 2001) 

In Healing Tasks, James I. Kepner talks about contextual healing.

Healing is not the curing of pathology. It is the creation of the healing context, where changes occur that could not occur before. This context is not limited to the therapeutic relationship. It must involve the survivor’s support, interpersonal relationships and human environment. 

Healing is not just a change within the individual survivor. It is a challenge and reformation of the whole field. It is a series of incremental developments that, taken as a whole, result in a truly transformational process.”(Kepner, 2003) 

 

Sources

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Berthold, Jessica (2009): “Do placebos have a place in clinical practice?” ACP Internist

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Cobb, L, Thomas, G, Dillard,D, Merendino, K, Bruce, R (1959) “An Evaluation of Internal—Mammary—Artery—Ligation by a Double—Blind Technic”: New England Journal of Medicine.

Craggs, Jason G., Price, Donald, D. Perlstein, William M., Verne, G. Nicholas, Robianson, Michael (2008):” The Dynamic Mechanisms of Placebo Induced Analgesia: Evidence of Sustained and Transient Regional Involvement”. The Clinical Journal of Pain

Egeth, Marc (2009): “Meta-meta-placebo and –curabo: You might get better just by reading this paper.” Medical Hypotheses.

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Ingrasci, Raz (2001): “Transformational Learning & Medicine: An interview with Matthew Budd, M.D.” The Hoffman Institute.

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Kepner, James (2003): Healing Tasks: Psychotherapy with Adult Survivors of Childhood Abuse. The Analytic Press.

Koyama, Tetsuo, McHaffie, John G, Laurienti, Paul J, Coghill, Robert, C (2005) “The subjective experience of pain: Where expectations become reality”. Proceedings of the National Academy of Sciences

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Moerman, Daniel E., Jonas, Wayne B. (2002): “Deconstructing the Placebo Effect and Finding the Meaning Response”. Annals of Internal Medicine.

Nauert, Rick (2009): “Perception of ADHD Behavior May Be Placebo-Induced” PsychCentral

Riddle, DL, Wade JB, Jiranek, WA, Kong, X (2009) “Preoperative Pain Catastrophizing Predicts Pain Outcome after Knee Arthroplasty”. Clinical Orthopaedicsand Related Research Journal

Talbot, Michael (1992): The Holographic Universe. Harper Collins.

Tilburt, Jon C, Emanuel, Ezekiel J, Kaptchuk, Ted J, Curlin, Farr A, Miller, Franklin G (2008) “Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists.”BMJ.

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