The placebo effect is a stark reminder that healthcare happens in the mysterious spaces between and within human beings; that it’s a skilled human activity and not simply a matter of applying technology. An overreliance on technical medicine may represent at best a defence against suffering; an inability to engage humanly is often a sign of practitioner boredom, burnout and depression. So it is ironic that although hard science is an incomplete basis for good practice, it now supports a resurgence in the art of medicine.
Each drug has its specific action, and the context in which a treatment is delivered will boost or reduce these effects. We now understand that these non-specific responses are far from being ‘all in the mind’, and that mental and relational processes can and do translate into biological changes. Neuroscience implicates multiple brain systems and neurochemical mediators, including opioids and dopamine (Tor et al, 2015). In the light of this emerging paradigm of the mind in the body and the body in the mind, it is unscientific to think of powerful contextual responses as incidental to the specific treatment, or to dismiss them as ‘mere placebo’.
In reality of course, we do not work in a vacuum and the art of communication has its proper place in all professional life. Yet these brain– – mind–body responses – ‘humaneffects’ influenced by the clinician’s belief in the treatment and the patient’s belief in the doctor – somehow blur the boundary between subjective mind and objective body. If, as seems to be the case, faith and hope get entangled in the prescription in ways that can trigger the body’s regulatory processes, how would it change practice if clinicians were to optimise these effects rather than ignore them? Could we learn to work wisely and well in this borderland? The question is particularly relevant where bio-technical medicine has limited success – in long-term conditions and relapsing illness – areas where the ‘medicalisation’ of suffering risks over-diagnosis and with it all the hazards of over-investigation and overtreatment. Are we ready for the logical next step? Since whatever goes into the mouth or the skin also goes through the imagination, should not those who prescribe do their best to optimise these context effects?
The article that follows was written at the inception of the BHMA, in the mid-1980s at a time when psychosomatic medicine still held some sway in primary care. Its psychobiological underpinning was but a twinkle in the eye of neuroscience, yet even back then Herbert Benson was defining the placebo response as ‘remembered wellness’. At the BHMA’s founding conference David Zigmond presented the paper that follows. In it he suggested that a chemically ‘inactive’ prescription could act as a symbolic reminder of attachment and ‘remembered safety’. All this Dr Zigmond poured metaphorically into an ‘inactive’ medicine, that induced calmness in his patient’s otherwise distressed body–mind each time it was taken. Arthur C Clarke famously said that any sufficiently advanced technology is indistinguishable from magic. Is the art of medicine actually a form of advanced technology, which now that science is overcoming the illusion that mind and body are separate, doctors will come to see as legitimate: whose mysterious and occasionally magical impact should be an essential part of their toolkit? Dr Zigmond offers three case studies that suggest we can incorporate faith, hope and love into our treatment materials.
Physicians must discover the weaknesses of the human mind, and even condescend to humour them, or they will never be called in to cure the infirmities of the body…’
Charles Caleb Colton, Lacon (1825)
It is not surprising that most contemporary observers and practitioners of medicine assume that drug treatment in medical and psychiatric practice is a kind of ‘pharmacological engineering’. A sample of any text or medical dialogue concerned with this subject is likely to support the notion of the doctor in his role of engineer; his diagnosis locates or defines a malfunction in the body, and his medical treatment is applied as a specific chemical remedy. The practice that follows is guided by purely technical considerations – finding the most specific drug for the problem, working out its route, dose and timing. Explanations as to how drugs work are similarly inclined – replacing depleted chemicals, neutralising acids, altering proliferation patterns in certain types of cell, inhibiting or catalysing specific chemical interactions – are common concepts used.
And yet while doctors and medical researchers work painstakingly to refine such scientific theory and its application, the patients themselves often have quite a different way of experiencing the doctor and his medicines. For example, the evidence that most drugs prescribed outside a supervised hospital setting are not taken at all, or not as prescribed (Parkin et al, 1976; Pearson, 1982) strongly implies that the doctor’s ‘scientific’ endeavours have quite a different meaning, or lack of meaning, for the patient. For all the technical talk among doctors of pharmaco-kinetics, serum concentrations, drug half-life and so on, if there is such a discrepancy between what a doctor assumes and intends and what a patient does, the questions arise ‘what is this activity, who is it for, and why does it exist?’ For the doctor, prescribing in the prescribed manner has a number of functions. It helps him pass the time with the patient in a way that offers him the security of familiarity, and confers on him the mantle of ‘physician’; a cloak of potency, authority and legitimacy. It legitimatises, too, his activities with his colleagues and gives him an identified place among them – they act in a similar way and so he is part of their group. It helps him feel helpful, even if this is not the help that is really needed; there are many studies suggesting this is often the case. The act of prescription may also provide the doctor with the comforting illusion that he is controlling or ‘managing’ the patient’s problem.
The foregoing indicates a little of why, for psychological reasons, the doctor may have his own compulsive need to prescribe. The main emphasis of this paper, however, deals with the complementary pattern – the psychology of the patient’s need for drugs – which is equally fascinating and important. It is well established that placebos can have a positive therapeutic effect in a very wide range of disease processes in any bodily system (Doongaji et al, 1978). Placebo response to severe injury pain (Beecher, 1955) and angina (Benson and McCalle, 1979) are now classic studies. Severe mental disturbance in those labelled ‘chronic schizophrenic’ often responds to placebos (Silverstone and Turner, 1974).
Some of the fragments of placebo psychology can be deduced from further research. A positive response depends upon an expectation of successful treatment (Lesse, 1962), a trusting and positive attitude to the administering doctors (Black, 1966), and the social status of the ‘healer’ (Silverstone and Turner, 1974). In this latter study, patients with a demonstrated peptic ulcer responded symptomatically to a placebo given by a doctor (70%), but much less with a nurse (25%). The deeper and symbolic meaning of the placebo – which this article discusses later – has received less attention. Among the most interesting studies is that of Balint (1970) who studied, over a period of some years, repeat prescriptions in general practice. He concluded that the repeat prescription often represented less of a treatment than a diagnosis – that the patient was wanting protection and reassurance from the doctor, but not direct contact with him. Such patients were emotionally needy but afraid of a more direct or intimate contact, and so settled for this ritualised ‘dose of doctor’ which represented a symbolic ‘something’ that was ‘good, reliable, unchanging and always available’. Clearly this need is similar, if not the same, to those needs of security and protection that run throughout our infancy and early childhood, and Balint here equated the drug’s symbolic protection and goodness with mother, or earlier, the breast. Certainly Balint’s notion was supported by the observation of protest, rage or crisis of some kind when the doctor attempted to stop or change the drug, usually with ‘clinically sound’ reasons – the drug for the patient was not a mere ‘pharmacological agent’, it was a symbol of caring, security and regard; its withdrawal seemed threatening to the patient, far beyond any possible medical implications.
Doctors’ training generally does not involve recognition of these important principles, and certainly the skills by which they may be marshalled and used therapeutically have received little attention. The ‘rational’, physical, components of prescribing have been pursued as a legitimate clinical study at the expense of those ‘irrational’, psychological, determinants which, as we have seen, may be decisive, for better or worse. This indifference, or implicit contempt for the placebo, seems to have coincided with the ‘pharmaceutical explosion’ in the 1950s (Doongaji et al, 1978). It seems that the world of medical therapeutics reflected in miniature much wider social processes – a consuming and increasingly exclusive interest in technology, at the expense of psychological and social needs that have been with us since our beginnings. The consequences of over-investment in technology and attention only to the manifest, at the expense of more radical but hidden human needs, is an increasingly pervasive theme in our culture.
The following three cases go back to the ‘irrational’ in treatment for their guiding principles. At first sight it might be easy to discuss them as in some sense ‘unscientific’ or ‘quackery’, but, on closer inspection, the skilful use of such situations and transactions involves some kind of applied science of the early mind.
Mr D, like Mrs F, was facing a dramatic and painful change in his life. While more concretely-minded sceptics might claim that his outbreak of shingles was coincidental to his wife’s death, it seems clear that the ‘treatment’ Mr D wanted from his doctor was of some kind of representation of the doctor’s understanding and permissive presence. Dr E had empathised with his aloneness and the grief and hurt that were expressed more by his body than by his words. The cream, for Mr E, was a way for him to have continuous, if symbolic, access to the palliative and nurturing presence of his doctor. The familiar religious symbols of Holy Bread and Water may confer on the believing recipient a sense of purification, forgiveness or strength; the clinical situation here is probably analogous, Mr D receiving from his cream a sense of caring attachment
Many writers and researchers have stressed the importance of touch in the mental and physical development of the young child (Spitz, 1945; Harlow and Harlow, 1966) and the continuing health of the adult (Berne, 1961). Healing or palliative procedures based upon touch have a long history, and are still prevalent in Eastern medical practice. For the distressed infant, the touch of a protective adult is probably the most effective non-specific remedy. Even as we grow older, touch remains among the most potent and direct antidotes to pain, panic and distress. Mr D’s choice of a ‘touching’ medicine – ’something to rub into my skin’ – probably indicated a wish for this most basic of comforts, as a balm for the most basic of pains; the loss of a loved person.
Comment and conclusion
There are a number of principles and metaphors we may use to describe and explain how this doctor made effective and sophisticated use of the most basic therapeutic tools.
He recognised that the disturbance in Mr S was occurring at an early child, even infantile, level of his mind, and that his communications had to be made accordingly. Reasoning, threatening or bargaining with Mr S’s ‘grown up’ part had been tried many times before and never with success. On the hypothesis that the outwardly aggressive Mr S harboured an inwardly frightened child reacting to some fantasised danger, Dr T knew that he must quickly make an alliance or rapport in a way that was both age and feeling appropriate. The careful choice of touch, simple words and eye-contact were designed to engender feelings of security and inclusion in Mr S, who was previously feeling alienated and turbulent.
It was not enough for Mr S to be ‘tranquillised’ in this way only while receiving Dr T’s attentions. His life had to be lived outside the consulting room, and Dr T had to find a way of helping his patient take with him an internalised representation of the doctor, which he would re-evoke at crucial times of stress and threat. Common notions of hypnotism usually call to mind formal procedures of trance-formation, but hypnotic suggestions may be made in ways far more various and subtle, as much recent work indicates (Brander and Grindler, 1975). Dr T’s deliberate emphasis of certain words, pausing at certain times and touching Mr S when he wished to make a particular impact, were all ways of ‘anchoring’ his message, of making a lasting hypnotic-association and imprint (Brandler and Grindler, 1979).
Long after the infant has drawn nourishment from his mother’s breast, he continues to draw a sense of comfort and security from the use of his mouth, particularly when sucking. The persistence of this need into adulthood is often masked, channelled and ritualised, but remains ubiquitous. Dr T used this most natural of tranquillisers very directly in his choice of a white, sweet ‘sucking’ medicine, and in doing so also took the opportunity to reinforce and anchor his earlier (hypnotic) suggestion.
As we grow into early childhood we have, increasingly, to learn to live without mother’s omnipresence and undivided attention. This difficult process of separation is often accompanied by various manifestations of fear, protest and anger on the child’s part, and he may often turn to an inanimate object as a source of solace. Teddybears, dummies, blankets are all familiar ‘transitional objects’ (Winnicott, 1958), helping the child face the unknown outside world. The child confers on the object special powers that once belonged only to mother. This need, too, persists into adulthood and is likely to become more intense in periods of stress and loss, where those much earlier feelings of peril and aloneness are reawakened. All three cases described illustrate the process where the doctor’s medicine had become a kind of transitional object. Mr D (Case No 2) faced his last years accompanied, not by a loved-one by his side, but by a tub of cream into which he projected loving qualities; a rather sad substitute, perhaps, but one which brought him great comfort.
In the film The Wizard of Oz the young heroine, Dorothy, believing in the Wizard’s powers, finds resources and courage in herself with which to confront the Wicked Witch of the West. She does not know, at first, that the Wizard is only an ordinary man with no more power than she; it is her belief in him which enables her to face those things she would have previously fled from. These principles, too, lay behind the successful placebo-effect in all three cases, and are well substantiated by experimental evidence (Lesse, 1962; Black, 1966; Silverstone and Turner, 1974).
The last principle I wish to outline is quite as important in practice. In the cases described, the practitioners entered into their patients’ mental world, in an intuitive and empathic manner, before confidentially prescribing the placebo. Recent investigators (Balint and Norell, 1972) described what they termed ‘The Flash’ in the medical interview where the doctor, leaving behind the usual protocol and ritual, is freer to understand the inner and existential dilemma behind his patient’s presenting complaints. While this often seems an essential component of successful placebo prescription so, too, is the skilled application of principles of how the child’s mind develops (developmental psychology), and how this ‘child-residue’ is manifest and operating in the adult (psychodynamics and psychopathology). This is particularly so when dealing with the kind of character problems illustrated by Mr S. The other two cases, depicting some kind of life crisis amid periods of rapid change and loss, but against a background of otherwise stable personality structure, are undoubtedly easier to deal with but involve similar qualities of interest, flexibility, dexterity and genuineness from the practitioner. It is interesting to note that these seem to be the most important elements of effective psychotherapy generally (Truax et al, 1966). Some practitioners might object that such endeavours are too time consuming to be practical. It is noteworthy, however, that even the relatively complex but crucial interview with Mr S took a little over 25 minutes. Dr T would probably have spent more time and energy dealing with the repercussions, had he refused to see his desperate but accessible patient.
Others might balk at the very idea of placebos, all too frequently used ineffectively and crudely as an act of blind, simplistic reassurance or, worse, a cynical and deceptive ‘quick trick’ to get rid of a ‘troublesome’ patient, under the guise of being helpful. However the intention and (lack of) scientific basis lying beneath such patterns of practice are quite different from the three cases described, where the process of diagnosis and selection was of quite a different order; they should not be confused.
In an age obsessed with increasingly complex technological activity and accompanying official (often vacuous) slogans such as ‘The Treatment of the Mentally Ill in the Community’ it is often a valuable challenge to re-examine and develop those more intimate and human skills that, despite protean fashions in technology, remain a cornerstone of practice. Healing involves far more than physical engineering. The placebo effect serves well as an example.
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